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PUBLICATIONS

i MASSACHUSETTS MEDICAL SOCIETY.

•

1
1

VOL. II. — N" 1.

%oM Jfekr or tako-%htal llemngitts

STATE OF MASSACHUSETTS.

; |

■

; k e r* o R t *..-..•

PRESENTED AT THE

ANNUAL MEETING OF THE SOCIETY,

MAY, 18 6 6.

BOSTON :

PRINTED BY DAVID CLAPP & SON.

MEDICAL AND SURGICAL JOURNAL OFFICE.

186 7.

PUBLICATIONS

OF THE

MASSACHUSETTS MEDICAL SOCIETY.

VOLUME II.

BOSTON:

PRINTED BY DAVID CLAPP & SON 334 WASHINGTON ST.

MEDICAL AND SURGICAL JOURNAL OFFICE.

1868.

The expense of printing the "Publications of the Massachusetts Medical
Society " is defrayed by a Fund devised to the Society by the late Dr- George
C. Shattlxk.

C ON TENTS.

Page.
Report on Spotted Fever or Cerebro-Spinal Meningitis in the

State of Massachusetts. By Luther Parks, Jr., M.D., Boston 3

History of Inoculation in Massachusetts. By J. M. Toner,

M.D., Washington, D. C. 153

Cases of Trichina Spiralis in Springfield. By M. Calkins,

M.D., Springfield 209

The Lessons of the War to the Medical Profession. By

George Derby, M.D., Boston 217

The Pathology and Treatment of Vaginal Cystocele. By John

Homans, Jr., M.D., Boston. 231

The Contagiousness of Cholera. By II. G. Clark, M.D.,

Boston .......... 245

Modern Surgery. By R. M. Hodges, M.D., Boston . 253

Improvements in Midwifery. By G. "YV. Garland, M.D.,

Lawrence ......... 265

Enucleation of the Eye-Ball. By B. Joy Jeffries, M.D.,

Boston 281

Extra Digits. By B. G. Wilder, M.D., Ithaca, N. Y. . 305

Recovery after Severe Injury to the Head. By J. M. Harlow,

M.D., Woburn . . . . . . . . 329

Case of Epilepsy, with Pathological Investigations. By M. G.
Echeverria, M.D., New York 351

Cases in Orthopedic Surgery. By Buckminster Brown,

M.D., Boston 361

REPORT OF A COMMITTEE

MASSACHUSETTS MEDICAL SOCIETY

SPOTTED FEVER OR CEREBRO
SPINAL MENINGITIS

IN THE

STATE OF MASSACHUSETTS.

MAY, 1866.

BOSTON:

DAVID CLAPP & SON, PRINTERS ... .334 WASHINGTON STREET.
Medical and Surgical Journal Office.

1867.

CONTENTS.

Preliminary Remarks,

The Spotted Fever of 1806 to 1815,

The Present Epidemic,

Symptoms and Post-mortem Appearances of the Present Epide-
mic AS COMPARED WITH THOSE OF THE EPIDEMIC OF 1806 TO 1815,

Correspondence between the foregoing and ' ' Epidemic Cerebro-
spinal Meningitis" as observed in France, .
Historical Notice of the Disease,
Conclusions from the Preceding Sketch,

Autopsies, . .

Treatment, ........

Page

31
34

42
45

Spotted Fever or Cerebro-Spinal Meningitis in Massachu-
setts since 1815, 49

Sporadic Cases, 49

The Endemic in Millbury and Sutton in 1849, .... 49
The Present Epidemic as relates to Massachusetts, ... 56
Spotted Fever or Cerebro-Spinal Meningitis in Public Civil Estab-
lishments of the State, 58

The Disease in the late Military Establishments within the State, 59
Spotted Fever or Cerebro-Spinal Meningitis not proved to be a

" Military Disease " by the late experience of Massachusetts, . 60
Over-crowding alleged to be a cause of the Disease, . . .61
Number of Cases in the Towns where there were Military Camps,

Proportion of Recruits affected,

The Cases of the Present Epidemic in Massachusetts (as collected
up to January, 1866), arranged in Tabular Form, . . .64

Results of the Tables, 67

Distribution of the Cases in Berkshire Countv, .... 67

Franklin " .... 67

Hampshire " . . . .68

Hampden " . . . .69

Worcester " . . . .69

Middlesex " . . . .70

Essex '" . . . .70

Norfolk " .... 71

Bristol " . . . .71

Plymouth " . . . .72

Dukes " .... 72

Nantucket " . . . .72

Barnstable " . . . .72

Suffolk " .... 73

The State at Large, .... 73

IV. CONTEXTS.

Some general Results of the Preceding Statistics, . . . .75
Does Proximity to Bodies of Fresh Water favor the Invasion of the

Disease? 77

Portion of the State most affected not that of the greatest " Rain-
fall," 79

Dates of the 3ases 79

Meteorology, 81

SourcesoftheDisea.se, 82

Locality : High or Low — Damp or Dry, 82

Occurrence of the Cases in Districts Thickly or Sparsely Settled, . 83

Condition of Patients 85

Ages 86

Sex 87

TTere the Cases Sporadic or Epidemic ? 87

Contagion, 87

Duration of the Cases, 89

Relapses, 92

Convulsions, 93

Headache, 93

Delirium, 94

Opisthotonos. 95

Tenderness at Nucha, 96

Pulmonary or Pleural Symptoms, 97

Abnormal Conditions of the Heart, including those of the Pulse, . 97

Abdominal Symptoms. 98

Petechia? or other Morbid Appearances of the Skin, ... 98

The Termination, 99

Autopsies — Treatment — Remarks, 99

Results of Autopsies in Massachusetts, 112

Results of Treatment in the Tabulated Cases, . . . .113

The Invasion of the Disease, 113

Reliability of the Cases, ' 114

Additional Cases 115

Probable Cases 116

Doubtful or Spurious Cases, 121

Pathologv, . 122

Discarded Opinions 122

The Typhus Theory, . 122

The Inflammation Theory, 128

Further Statements of Opinions concerning Spotted Fever, . . 132

Connection with Diphtheria, 134

Diagnosis, 135

Prognosis, 136

The Nomenclature. 136

Appendix, 139

PRELnnXAEY REMARKS.

At the Annual Meeting of the Massachusetts Me :
3 iety, held May 31st. 1865, it was Resolved. '• Tha: i

^imittee of one from each District S ::ety be appoir.-
the President, whose duty it shall be to report at the iri:
Annual Meeting of this Society, upon the prevalence of the
disease called ■ Cerebro-Spinal Meningitis, or Spot! ed Fe-

ver.' "

The Committee u subsequently appointed :;r_~ ;^7ed of
Dr. Luther Parks, of Suffolk County, Chairman : Dr. Gr. W.
Doane, of Barnstable County : Dr. X. S. Bat birr, of Berk-
shire : Dr. Charles Howe, of Xorth Bristol : Dr. F. H. Hooper,
of South Bristol ; Dr. E. P. Fearing, of Dukes and Xantucke: :
Dr. Wm. D. Lamb, of Xorth Essex : Dr. H, 0. Stone, of South
Essex: Dr. J. W. D. Osgood, of Franklin: Dr. P. L. B.
Stiekney. of Hampden : Dr. A. XT. IL iiapsc n, of Hampshire:
Dr. Ephraim Cutter, of East Middlesex : Dr. X. B. Bdwai
of Xorth Middlesex : Dr. Alfred Hosme: : : S :-uth Middle-
sex : Dr. C. C. Tower, of Norfolk: Dr. H. N. Jones :f Ply-
mouth: Dr. Joseph Sargent, of Woi -:er: Dr. T. B. B: i-
telle, of North Worcester.

In the notifications sent to us of our appointment, it is
stated that the '"'subject submitted to the Commrno e ie

Sj rtted Fever in Massachusetts." Therefore, though the
resolution above quoted diro eta ms. in general terms, to report
on "the prevalence of the Disease called Cerebro-Spinal
Meningitis" or ' : Spotted Fevf: ' it is the history :
malady as it has occurred in this State that we have
investigated, and upon which we now offer our rep t
1

REPORT.

THE SPOTTED FEVER OF 1806 TO 1815.

Some half a century ago there prevailed in Massachusetts
and other parts of New England, an epidemic called " Spot-
ted " or "Petechial Fever; " and we must necessarily begin
with some notice of that. By the direction of the Massachu-
setts Medical Society, a report upon that epidemic was in the
year 1810 drawn up by a committee, on which were some of
the most distinguished names in our profession. And though
the question whether the Spotted Fever of 1810 was the
same as the epidemic of to-day which is called by that name,
has not been hitherto settled, yet notwithstanding the respect-
ful distance of fifty-six years intervening between the report
of 1810 and that of 1866, it is with sentiments of the utmost
deference and diffidence that we * find ourselves, in some
sense, the successors of such names as James Jackson and
John C. Wareen.

In relation to that report, the writer of this has been
favored with a letter from, and a personal interview with
Dr. Jackson, by whom almost the whole of the former one
was written. Our venerable father in medicine warns us to
receive some of the statements quoted cum grano sails. He
reminds us that the morbid anatomy of fifty years ago was
not what morbid anatomy is now ; that observers may have

4 REPORT.

sometimes erroneously thought they saw what they expected
to see ; that on opening the brain, for instance, they may have
pronounced that to be vascular congestion, which at the
present time would not be considered a morbid appearance.

The materials for his report, Dr. Jackson says in his let-
ter, " were furnished by a very few of the persons to whom
queries were addressed, the same in kind as those in your
first circular, but the replies were Very few, and gave more
opinions and theories than facts, so far as I recollect." . . .
u In later years, I have met with a single case now and then,
which I regard as the old spotted fever. I had one singular
case, two or three years ago, in a school-master under the
care of Dr. J. W. Warren." .... "About 1853, a very
singular case occurred in a woman, domestic in my own
house. Her disease was a very brief one, and it was after
her death that I came to a conclusion about it. I have not
any notes of these cases."

The above statement of Dr. Jackson that he had seen
sporadic cases of spotted fever, occasionally, since the epi-
demic of 1806 to 1815, we regard as a very interesting one.

It might be thought superfluous to offer, for re-publi-
cation here, anything which had already been printed in
the Transactions of this Society. But we feel compelled
to reproduce, among other citations, extracts from the report
of the committee of 1810 (copies of which are rare), for the
sake of comparing the old spotted fever with the recently
prevailing disease which has received that name.

The " old " Spotted Fever first attracted attention by its
appearance in the town of Medfield, Massachusetts, in 1806.
Between the 8th and 31st of March, 1806, nine cases occur-
red in that town, all of them fatal. It then showed itself in
other parts of the State and also of New England, subse-
quently extending itself to New York, Pennsylvania and
Canada; also to Kentucky, North Western Virginia, and
finally to the southern extremity of the United States. The

CEREBROSPINAL MENINGITIS. 5

Committee's report, presented June 2 1st, 1810, traces its
course in Massachusetts for the preceding Winter and
Spring. After saying that the first part of the Winter, as
also the Summer and Autumn of the year before, had been
remarkably healthy throughout the country, it states that the
disease appeared first in the town of Dana, about the begin-
ning of the year, but not in any considerable number of in-
stances until during the cold weather after the middle of
January. It is then heard of at Petersham in the latter
part of February, and at Barre, Oakham, Rutland, Paxton,
Hardwick, New Braintree, Brookfield, Spencer, Sturbridge,
Winchendon, Athol, Gerry, Leicester, and Worcester, in the
course of the month of March, mostly about the third week
in that month. The above mentioned towns are all in the
county of Worcester. It occurred in Cambridgeport, Mid-
dlesex county, in the suburbs of Boston, on the 24th of
March, and in April at Lancaster, county of Worcester. In
the course of April and May a few cases occurred at Boston,
and " perhaps an equal number in proportion," in the coun-
ties of Worcester and Middlesex. During May it appeared
in Springfield, Hampshire county, and had not subsided in
the second week of June.

Most of the country above indicated is, the Committee
point out, inland and very elevated, having many fresh water
ponds and streams. In Cambridgeport the disease was
mostly confined to land which had been recently salt-mea-
dow, and intersected by foul ditches. In Boston this disease,
as also " typhus," had occurred mostly in those parts of the
town near the fiats and water.

On the whole, however, the epidemic was found to have
occurred in seasons differing in their meteorological charac-
ter, and in places very various in their soil and climate.*

* The authority for this statement is an unpublished manuscript of Prof. 0.
W. Holmes, which, together with valuable books, he most kindly lent me to aid
in drawing up this report. L. P., Jr.

6 REPORT.

Drs. Bigelow and Holmes, in their edition of Marshall
Hall, give the following summary of the symptoms of the
disease ; viz., sense of lassitude, great prostration, faintness
at stomach, sinking of the pulse, coldness of surface, occa-
sionally chills, pain in the head, coma, delirium or convul-
sions, vomiting, in some instances approaching that of cholera
morbus, and the appearance of petechia, or spots of effused
blood beneath the epidermis. To this should be added the
not unfrequent occurrence of severe itching of the surface.
Dr. North* mentions sore throat as a premonitory symptom
to be found with but few exceptions when inquired for ; so
slight, however, that most- patients do not mention it unless
questioned. Redness of the throat and aphtha? were some-
times observed.

The eruption which gave the name of Spotted Fever to
the disease was not constant, and was less frequent in the
year 1808-9, than in the two years preceding. Dr. Henry
Fish, giving an account of the disease in Hartford in 1809,
says that in that place it was without spots, at least before
death. The Committee of 1810 say it was not easy to de-
termine in how large a proportion of subjects I the skin was
affected with spots and eruptions. One .of their observers
had seen only four instances of cutaneous affection in eighty
cases, while another estimated it to have occurred in two
thirds of all his cases. This last reporter, however, we are
told, included very slight affections.

As to the character of the eruptions, the Committee say
they were very various : such as red spots only, miliary erup-
tions, blotches, vesicles, sometimes resembling blood blis-
ters, pustules, and rarely purpura, petechias, or vibices.
Sometimes there was an appearance like measles. Dr.
Strong says the spots did not rise above the surface, nor
recede upon pressure. They appeared upon the face, neck,
and extremities, and frequently over the whole body.

* North on Spotted Fever, 1811.

CEREBRO-SPINAL MENINGITIS. 7

The invasion of the disease, say the Committee, is gener-
ally sudden and violent. In its course all the functions
of the body are more or less interrupted, and often some of
them are entirely suspended. The subject of it is seized in
the midst of his usual labor or occupation, and oftentimes
is struck down suddenly, almost as by a stroke of lightning.
The first symptoms are various, such as local pain or para-
lysis, delirium, or coma, and rarely spasms or convulsions.
Sometimes, though less often, says Dr. Hale,* the inception
was slow and gradual, occupying several days. But, in what-
ever form the disease began, there ensued, and generally
suddenly, great prostration of strength — a point much dwelt
upon by writers.

The access often consists of shifting pains. The patients
suddenly feel a pain in one joint or one limb, often in a
finger or toe, in the side, stomach, back, or head. Some-
times the sensation is like the stinging of a bee, frequently
it is most excruciating pain which at once arrests and com-
mands the whole attention. This pain moves from place to
place without losing its violence, generally approaching the
head, and it is often confined to one side of the body.f

Observers concur in stating that every symptom was not to
be found in every case. On the contrary, there was great
variety in the symptoms, and great variety also in the order
in which they occurred.

In the Committee's report, the only mention we find of

* Hale on Spotted Fever, 1819.

f In a work of Drs. Miner and Tully on Fevers (1823), is a notice of an epi-
demic which had prevailed for the eight years previous to 1822, in some parts of
Virginia, and which the authors consider to have been a typhoid pneumonia. In
that set of cases, there were some in which, instead of the chest, various other
parts of the body would be affected with ". a most excruciating pain." The attack
occasionally began with pain in a finger or toe, or other parts of the extremities.
In this connection, we will mention that Dr. James Jackson informs the writer
that about the time, or shortly after the subsidence of the epidemic known as
" Spotted Fever," which we are now describing, there prevailed in Vermont a
pneumonia of a typhoid character, which had many characteristics in common
with "Spotted Fever."

8 KEPORT.

opisthotonos is in the following passage : " Spasms which fre-
quently occur and shift suddenly as the pain does from part
to part; sometimes resembling hysteric spasms, sometimes
occasioning the head to be drawn back as in opisthotonos.''''
But Dr. North mentions among " the more unusual symp-
toms " " a kind of clonic spasm of the muscles of the neck "
(p. 15). He also says (p. 129) in the bad cases there were
pain of the head and universal distress and agony, which
would cause children to draw back their heads. Dr. North
relates the case of Hannah Dresser, ast. 20, who in a relapse
of the disorder had frequent spasms, sometimes of the limbs,
sometimes of the neck, (l drawing her head back like opistho-
tonos ;" also that of Andrew Ellicott, aet. 6, who had strong
spasms frequently recurring, by which his head was drawn
backwards " like a person affected with opisthotonos." In
this case the opisthotonos was subsequently replaced by a
strabismus. Again, Dr. Samuel Woodward, of Torringford,
Conn., in a paper quoted and commented upon by Dr. North
in his book, mentions, among " the violent symptoms " ob-
served in his own " experience," that the head was " drawn
back with spasms." President Fitch also speaks of " pain
and rigidity of the muscles of the neck often," and says the
head is in many instances bent backwards.

Relapses occurred in many instances, but were rarely if
ever followed by death."* And, according to Dr. North, the
disease was not self-protective. He gives a case of a patient
who had spotted fever in 1808, and again in 1810.

Fatal cases terminated in twelve, twenty-four, or forty-
eight hours. In favorable cases reaction took place, and a
mild fever of uncertain duration followed.f

The disease was of various degrees of severity : in a
large proportion of cases very mild ; in some severe, and,
in a few, destroyed life " like the plague." The communica-

* Dr. Holmes's unpublished writings.

t Drs. Bigelow and Holmes in Marshall Hall's Practice of Medicine.

' CEREBROSPINAL MENINGITIS. 9

tions made to the Committee of 1810 related to the disease
in its gravest forms.

With regard to the fatality of the malady, the Committee
of 1810 say they were unable to make " any accurate state-
ments," but that at the first appearance of the disease in the
County of Worcester a very large proportion of those af-
fected with it died at an early period of the affection. After
it had extended more widely, its violence diminished, and
the proportion of deaths became very small. The Com-
mittee say that women in different stages of pregnancy have
been known to recover from severe attacks of spotted fever.

Statements differ as to the influence of age and sex, ex-
cept that neither very young infants nor aged persons were
so subject to the disorder as persons in middle life. No-
thing further was ascertained upon the question of the
causes, save that it prevailed mostly in cold weather, and
that there was no suspicion of its contagiousness.

As to the treatment pursued in the old epidemic it may
be worth noting that the extreme prostration led to active
stimulation (which was carried by some practitioners to an
absurd excess ; to the extent of a quart of brandy, for in-
stance, in eight hours) ; and that the free use of opium was
commended by some, as it has since been by late Continen-
tal writers in what is called by certain of them " epidemic
cerebrospinal meningitis " — the malady which is now prevail-
ing among us, under the name of " cerebro-spinal meningitis,"
or " spotted fever." There were of course, at the period
when the disease of which we are writing prevailed, prac-
titioners who, like Dr. Gallup, used blood-letting and other
antiphlogistic remedies ; but the general sentiment seems to
have been that spotted fever was an asthenic affection, and
should receive a supporting and stimulating treatment.

Autopsies in this epidemic were not numerous. Dr. Hale,
in his large experience of it in Gardiner, Maine, did not

10 EEPORT.

obtain one. The Committee of 1810, however, give reports
of a few. The post-mortem appearances may be summed
up as follows :

HEAD.

In some instances turgescence of the cerebral vessels was
the only lesion found. This was generally in cases of short
duration, i. e. in which death occurred in from twelve to
twenty-four hours. In cases of longer continuance, there were
found bloody points in the medullary substance of the brain,
effusion of serum, the arachnoid and pia mater remarkably
altered in appearance by the effusion of an opaque substance
between them, " which may be called coagulated lymph, or
semi-purulent lymph. This substance was frequently of the
yellowish color of pus, with a consistence between the tena-
city of lymph and the fluidity of pus." At other times
it resembled well characterized lymph. There was some-
times adhesion of the hemispheres of the brain to the dura
mater and to each other.

THORAX.

The Committee say that in every instance of which they
were cognizant, the small vessels of the surface of the heart
were beautifully injected. Lymph was sometimes found on
the pericardium ; and the endo-cardium was " occasionally
altered from its healthy texture." Less frequently traces of
inflammation were found on the pleurae. In one case which is
given below, the cavity of the thorax was the seat of very con-
siderable disease, including apparently pulmonary congestion.

ABDOMEN".

The liver and spleen, says Dr. Holmes (op. cit.), are re-
ported " to have been distended in various degrees, and free
from any morbid change except an extremely livid color.
The state of the stomach and intestines is so imperfectly

CEREBROSPINAL MENINGITIS. 11

described that it is hardly possible to draw any conclusion
respecting the morbid changes they may have undergone."

By way of illustration, we now give from the report of
the Committee of 1810, descriptions of three autopsies which
were performed by the late Dr. John C. Warren. With
the first of these we copy the brief record of the symptoms.
The second was the case referred to above, as showing
marked traces of inflammation in the chest.

Case I. The patient was a child of Mr. Gleason, aged
eighteen months. The child, from being perfectly well and
playful, was suddenly attacked with shivering fits, became
stupid, and gave symptoms of severe pain in the head and back.
Its skin when first noticed was livid and cold, but afterwards
hotter than natural, though the heat did not continue long,
and was succeeded by an unusual coldness. The tongue
was coated with a light-colored mucus. The stomach was
nauseated, and occasionally ejected such matters as had been
lately swallowed. At the end of about twenty-four hours,
the child exhibited some favorable symptoms. The pulse,
which was before very much depressed and irregular, be-
came distinct and less variable ; the countenance was reani-
mated ; the coma was succeeded by a return of sensibility
sufficient to enable the child to recollect those around it.
These flattering appearances lasted but a short time ; the
coldness and insensibility returned, the pulse became imper-
ceptible, and the patient sunk in about thirty hours from the
attack.

Dissection, nineteen hours after death.

external appearance.
The body exhibited on its anterior parts a considerable
number of irregular purple spots, and a few regular ones.
The back part of the trunk was of a very deep and uniform
purple color.

12 REPORT.

HEAD.

The superior longitudinal sinus was full of dark-colored
blood, which had partly coagulated. The external surface
of the dura mater had nothing remarkable. When this
membrane was divided, a quantity of serum was discharged,
which was transparent on the left side, and bloody on the
right. The child had been on the latter side from the mo-
ment of attack. The bloodvessels ■ were not very full of
blood ; for a large quantity had been discharged from the
longitudinal sinus. These vessels were generally covered
by a substance, which accompanied them in the greater part
of their course, bearing a resemblance to coagulated lymph
in consistence, but approaching pus in color. Besides these
portions there were many smaller masses situated in various
places between the pia mater and tunica arachnoides, espe-
cially near the vertex and between the hemispheres of the
brain. The thin coats were glued to the dura mater at the
upper edge of the hemispheres, and the hemispheres were so
strongly connected by these coats under the falx, as to re-
quire the aid of a knife for their division.

The superior parts of the cerebrum being removed, so as
to expose the medullary substance, this was seen full of small
reel points, placed in clusters, which increased in size after
a few minutes. The lateral ventricles were quite full, but
not over distended with serous fluid. The plexus choroides
was swelled but of a pale color, and its velum interpositum
thickened by the same kind of lymphatic substance which
has already been described. The third and fourth ventricles
exhibited no peculiar appearance except the water which
they necessarily contained. The superior part of the cere-
bellum and the inferior part of the cerebrum and cerebellum
had a large quantity of the yellow colored lymph. The
base of the cranium contained serous fluid. The consistence
of this brain was healthy.

CEREBROSPINAL MENINGITIS. 13

THORAX.

The lungs were of a light color on the fore part, and
dark behind, as is usual in healthy lungs after death. Their
consistence was natural. Their contents were a proper quan-
tity of frothy mucus. The heart was very firmly contracted.
The right cavities were full of black blood; and the left
empty. The vessels on the surface of the organ were mi-
nutely injected with blood.

ABDOMEN.

The liver was large and turgid, and of a very livid color.
On dividing it, great quantities of black blood were poured
out. The gall bladder was moderately full of yellowish
bile. The external and internal coats of the stomach had a
perfectly healthy appearance. Its contents were a dark-
colored fluid of vinous smell, similar to that of the substances
taken before death. The coats of the small intestines were
healthy. Their contents were yellowish in the first portion,
and green near the caecum. In the latter was a large dead
lumbricus. The large intestines contained flatus without
any offensive smell, and a considerable quantity of well-
digested fasces. The spleen and pancreas had nothing re-
markable. The kidneys were quite turgid, and discharged
urine on being pressed. The bladder was full of urine.

The muscular fibres were livid, and of a natural strength.
The blood was very dark colored, and coagulated after being
discharged from the vessels.

Case II. The next case was that of a man set. 39, of a ro-
bust habit. The attack began with a chill three days after an
exposure to rain, while he was much heated by working.
Among the symptoms were cough, attended with a copious
expectoration* of " mucus of a common appearance," difficult
respiration, and great "uneasiness about the breast,"

14 REPORT,

AUTOPSY.
EXTERNAL APPEARANCE.

The body became covered with irregular purple marks of
various size, about half an hour after death. The face was
turgid, and this part and the shoulders were very livid.
The blistered parts were quite dark colored and bloody.

HEAD.

The hemispheres of the brain adhered by their thin coats
to the dura mater, and to each other. Between each of the
meninges was some serous fluid, and an effusion of coagula-
ted lymph. The last was most conspicuous over the blood-
vessels, which were full of dark blood. The cortical sub-
stance was pale. The lateral ventricles were much larger
than natural, from being distended by a transparent serum.
The meninges at the basis contained coagulated lymph, and
under them was a quantity of serum.

THORAX.

The fore part of the lungs was covered with a very thick
layer of yellow coagulated lymph, which extended from the
pleurae of the lungs to the pleurae of the ribs, fixed these two
parts together, and then passed along the side of the cavity
toward the spine. The right cavity contained a quantity of
pus which was judged to amount to thirty-two ounces. The
substance of the lungs was rather firm ; yet they had not
that kind of hardness which is produced by common inflam-
mations of the lungs. The surface of these organs was
shrivelled. Their color was peculiarly livid and unhealthy.
The degree of firmness they possessed may be attributed to
their containing more blood than is usually collected in those
parts after death. The pericardium had a very little water.
The heart was inflamed on the anterior face, and had a thick
flake of coagulated lymph near the apex, and another on

CEREBROSPINAL MENINGITIS. 15

the origin of the aorta. The cavities were equally filled
with coagulated blood.

ABDOMEN.

When this cavity was opened there was not any very offen-
sive odor emitted. The stomach was perfectly healthy in every
respect, and did not contain any fluid. The intestines were
in a healthy state. The liver was shrunk, and that part of
its coat next the diaphragm bore marks of slight inflamma-
tion. The gall bladder was quite distended with dark tena-.
cious bile. The rest of the abdominal viscera exhibited no
remarkable appearance except the urinary bladder, which
was distended with urine.

The blood and the muscles were of an exceedingly dark
color.

In the above case inflammation of the meninges was com-
plicated with inflammation of the serous- membranes of the
chest, together with probable congestion of the lungs.

Case III. The subject of the third case was forty years
of age — of good constitution.

external appearance.

The petechiae were less distinct than before death; the
vesicles and efflorescence disappeared. The countenance
and eyes not much altered.

HEAD.

The meninges of the brain contained a small quantity of
serous fluid, and also a very considerable and uniform effu-
sion of coagulated lymph. The hemispheres adhered to
each other. The ventricles were full, but not over distended
with water. In the basis of the cranium was a considerable
quantity of yellowish fluid. Under the cerebellum and the

16 REPORT.

tuber annulare lay two large masses of lymph which com-
pressed those parts, and indented themselves in their sub-
stance, especially flattening the last-named part.

THORAX.

The lungs had a healthy aspect. They were anteriorly
light, and posteriorly dark colored. The heart was inflamed.
The minute branches of the coronary arteries were rendered
distinct by blood thrown into them. Near the apex and on
the origin of the aorta were exudations of lymph. The
yalves of the organ were opaque ; the cavities empty ; but
the aorta was full of black blood.

ABDOMEN.

The liver was of a good color and moderately distended
with blood. The gall bladder was full of dark, tenacious
bile. The stomach- had two or three small spots of inflam-
mation in the mucous coat ; it contained some dark-colored
fluid, and a little greenish mucus. The small intestines were
in a healthy state, except a part, which was rather more red
than the rest. The large intestines were contracted to a
rope, except the rectum and part of the colon, which con-
tained an alcoholic injection. The pancreas, spleen and
kidneys had not anything worthy of note. The bladder was
filled with urine.

The muscles had a livid color ; so had the blood. This
fluid coagulated after escaping from the vessels.

We insert here two cases which occurred in Brookfield,
Worcester County, although they are dated in 1816, after
the disease had ceased to be considered epidemic. These
cases, hitherto unpublished, were furnished us through the
kindness of Dr. John Homans, of Boston, in whose practice
they took place while he was a resident of Brookfield.

CEREBROSPINAL MENINGITIS. 17

Case IV. On the fifteenth of April, 1816, M. S., a girl
aged fourteen, large for that age, and in all respects enjoying
good health, complained of headache, about 4 o'clock, P.M.,
which increased so she was compelled to take her bed at
7 o'clock.

She was restless and could not sleep, and notwithstanding
the application of remedies, such as mustard plasters to the
back of the neck, mustard baths to the feet, cold water to
the forehead, &c. &c, she got no sleep. At 4, A.M., I saw
her. The skin was cold and a profuse perspiration had
commenced an hour previous ; the eyelids were drooping.
The surface of the whole person was covered with petechias,
the spots being large as a quarter of an inch in diameter —
on the face and neck varying in size to a mere point ; and
on the body and extremities much smaller than on the face.
Color did not disappear on pressure. Pain in head and
back of neck intense, mind confused, pulse 100, weak and
irregular. At 6, lost power of speech, and died about 8,
A.M. There was no convulsion, but slight opisthotonos.
The above case occurred in the town of Brookfield ; house
situated on a slight elevation, a meadow lying on the south-
west, and west of it. The family were in easy circum-
stances, and enjoying good health.

Case V. On the fifth of May following, visited Miss C.
A., aged 19, who had been in good health (though never
robust) until the day previous, when she complained sud-
denly of headache, when at a short distance from home —
so intense as to compel her to return. The pain I believe,
in this case, was more severe in the back of the head, and
upper part of the spine. In the after part of the day, she
had nausea, faintness, pulse between 70 and 100, and feeble.
Petechias commenced appearing in the evening, not so large
or so numerous as in the other case, but, as in that, of a
3

1 8 EEPORT.

deeper hue, and larger size on the face, than elsewhere ;
slight delirium followed, and her mind continued confused.
Occasionally a slight convulsion occurred, and, as in the first
case, slight opisthotonos, until death took place at the end
of about 30 hours from the onset of the disease.

The locality in which the house stood was healthy, neither
low nor much elevated, but sufficiently high not to allow
water to remain stagnant. The father was a wealthy farmer.

No examination was allowed in either case.

What was the disease we have been describing? Dr.
Holmes declares (op. cit.) "it is easier to say what it was
not 'than what it was." He then goes on to say it was not
scarlatina or angina maligna, as some supposed, else the
character of the complaint would have been obvious in the
mild cases, at least, of which there were great numbers.
It was not pneumonia typhoides, he further remarks, because,
according to the report of the Committee of the Massachu-
setts Medical Society, the structure of the lungs is not com-
monly deranged. Dr. Hale, speaking of the spotted fever
of his day, versus typhoid fever then called typhus, says if
"typhus " (typhoid) is to be considered a particular disease,
the fever under consideration was not a " typhus," for it did
not exhibit the characteristic symptoms which belong to that
disease. It had not the regular approach, nor the uniformi-
ty of appearance of typhus. Its progress was more rapid,
its features more variable, its changes more abrupt, and its
termination more sudden. Dr. Holmes again (op. cit.) takes
ground against the theory that spotted fever is a form of the
British Typhus, in the following words : " A disease which
was hardly suspected of being contagious, which was gener-
ally fatal in the first two days if at all, and was considered by
experienced observers as free from clanger if the patient
survived the third day, in which the mortality varied from

CEREBBO-SPINAL MENINGITIS. 19

one in two, or a still higher , rate, to one in a hundred, and
above all, which selected the villages of the interior for its
ravages, and though it showed itself in the immediate neigh-
borhood of the capital of New England, never attracted any
notice, if it appeared, at all, within its walls — such a disease
presents too many points of difference when compared to
British typhus to admit of being forced into the same cate-
gory." Finally, while acknowledging the resemblance of
the symptoms of the epidemic to those of the pernicious
algid fever of malarious districts, he maintains that since
" the disease did not present the intermittent or remittent
character when its course was protracted, that the lesion of
the spleen and the sequelae of these diseases do not appear
to have been present, that it prevailed at a season when
they do not usually make their appearance," it is sufficiently
proved that there is an essential difference between the
spotted fever of 1806 to 1815, and the various forms of
intermittents and remittents.

The Committee of 1810 came to the conclusion that their
spotted fever was fever combined with internal inflammation,
and that the inflammation was commonly erysipelatous ; fre-
quently of a character intermediate between erysipelatous
and phlegmonous.

As erysipelas is an inflammation of an asthenic character,
this definition is suggestive of the term used by Drs. Miner
and Tally to designate the disease in question, viz. : Phre-
nitis Typhodes.

Dr. Tully, however, considered the spotted fever of his time
to have appeared in some cases in the form of typhoid pneu-
monia. An epidemic of typhoid pneumonia, so much resem-
bling the spotted fever as to be called by some a modification
of that disease, prevailed in the Northern Division of the U. S.
Army from 1812 to 1813, principally at Plattsburg, Burling-
ton, Greenbush, and Buffalo. It was frequently fatal in twenty-

20 KEPORT.

four hours, but more often the patient survived from four to
six days.* Two other forms of the spotted fever were also
recognized by Dr. Tully ; so that he made in all four forms,
viz. : typhoid phrenitis, typhoid pneumonia, typhoid hepatitis,
and typhoid enteritis. Dr. Tully appears to have believed
the typhoid inflammation in all these alleged phases of the
spotted fever to be the disease, with no other lesion behind it
in the chain of causation.

The epidemic we have been describing seems to have
been lost sight of after the year 1815; and though Dr.
Jackson has up to within two or three years met with a
sporadic case now and then, spotted fever has till a short
time since been known to most of the present generation of
physicians only as a historical curiosity.

THE PRESENT EPIDEMIC.

Half a century having elapsed since the report of the
Committee of 1810, and during the height of the devastating
war, which has just closed, the attention of the profession is
called to an epidemic different from any disease the observers
had met with before, and attacking various and distant parts
of the country. As in the old spotted fever there were, in
many instances, petechias and other spots ; like that epidemic,
the disease was at first mistaken by some for scarlatina,
an error which was soon laid aside ; like that, it was thought
to be assimilated to intermittents or remittents, while on

* Trans. Phys. Med. Society, New York, 1815 to 1817.

CEREBRO-SPINAL MENINGITIS. 21

reflection it was readily seen that it occurred at a season of
the year when miasmatic diseases do not prevail, and among
persons who had not been exposed to malarial influences, or
if exposed, less so than their companions who escaped the
affection ; and also, that it was not amenable to the treat-
ment which usually controls periodic disorders ; like the old
spotted fever, it was considered by some as a form of the
British typhus ; by others denied such a classification ) and
for the same reasons that led the old spotted fever to be dis-
tinguished from typhus. By some, like the former epidemic,
it was, and is, called " spotted fever," on account of certain
cutaneous eruptions which show themselves in many cases.
Others, seeing that these symptoms were not universal, and
that cerebro- spinal symptoms were much more decidedly
characteristic phenomena, while at the autopsies inflammatory
or congestive appearances of the cerebro-spinal membranes
were very generally found, gave it a name conformed to
those symptoms and appearances, and corresponding some-
what to the pathology adopted by the Committee of 1810,
as well as to that of Drs. Miner and Tully in selecting the
term " phrenitis typhodes," viz. : cerebro-spinal meningitis,
or epidemic cerebro-spinal meningitis.

Symptoms and Post-moetem Appearances of the present
Epidemic as compared with those of the Epidemic of
1806 to 1815.

One of the ablest papers published on the present epi-
demic, that which at an early period brought it prominently
before the profession, was by Dr. J. B. Upham on " Con-
gestive Fever (so called), or Epidemic Cerebro-spinal Me-
ningitis as it occurred in the winter and spring of 1862-63
in the Camps in and around the town of Newbern " [North
Carolina] .

We proceed at once to give Dr. Upham's summary of the

REPORT.

symptoms and morbid appearances, as presenting an admira-
ble picture of the disease. Side by .side with the former we
give the corresponding symptoms of the spotted fever of
1806-15, subsequently mentioning the differences between
the two, in order that some idea may be formed whether or
not the epidemic of to-clay is the same disease as the old
spotted fever.

The passages from Dr. Upham's paper which are italicized
have no corresponding ones from other authors.

Dr. Upham's Summary of the
Symptoms of "Epidemic
Cerebrospinal Meningitis"
in 1862-63.

I. " In its mode of attack the
disease was commonly sud-
den and without premoni-
tion, the patient for the most
part continuing on duty and
making no complaints till
the very day of his seizure.
Some of the most violent
cases thus commenced.
Case XII. is in point, where
the soldier appeared with
his company at the evening
dress parade, complained of
chilliness, headache, &c,
during the night, and was
dead within thirty-six hours
following.

II. And the subjects of the
disease in most cases were
those previously in the ful-
ness of robust health.

Corresponding Statements re-
lating to the Spotted Fever
of 1806-15.

I. "The invasion of the dis-
ease is generally sudden
and violent. * * * The sub-
ject of it is seized in the
midst of his usual labor or
occupation, and oftentimes
is struck down suddenly
almost as by a stroke of
lightning." — Mass. Medi-
cal Society's Report, 1810,
p. 122 of " Medical Pamph-
lets " in Public Library of
Boston.

II. " By some gentlemen it is
remarked that females are
more subject to the disease
than males, and this was
true in Worcester, the only
town from which we have
received a list of the sick.
Yet one gentleman states
that it attacks most espe-
cially the most healthy and
robust, male and female." —

CEREBROSPINAL MENINGITIS.

III. The symptoms were at
the first headache, referred
oftentimes to the back part
of the head particularly.

IV. With dizziness —

V. Pain in the back and limbs,
this last occasionally of an
excruciating character.

VI. With sometimes rigors.

VII. Nausea and vomiting.

VIII. Chilliness rather than a
well defined chill character-
ized the accession of the
disease.

Mass. Med. Society's Re-
port, 1810, p. 136.

III. The head is more fre-
quently affected with pain
than any other part ; and
when not affected at the
first moment, it almost in-
variably becomes so in a
short time. — Ibid. p. 122.
Hale says " the head and
back/' p. 55. Williamson,
quoted by North, says in
some the pain was in the
" back of the head, extend-
ing down the neck.77

IV. Hale mentions dizziness
frequently. " The most com-
mon mode of attack was by
a violent pain in the head
and dizziness.7' — P. 54.

V. " In the earlier part of the
epidemic period, the disease
always commenced with
severe pain in some part of
the body, which, if it did
not begin there, soon ex-
tended to the head and
back.77 — Hale, p. 55. —
North, and M. M. Soc. Re-
port say " excruciating 7;
pain.

VI. "This prostration is ac-
companied or followed by
universal or partial chills.77
— M. M. Soc. Report, p. 124.

VII. " Frequently eructa-
tions, nausea and vomiting
ensue.77 — Ibid. p. 124.

VIII. Among the symptoms
in " the most common mode
of attack,77 Hale reports
" chilliness,77 p. 54. Again,
p. 5t, " At a later period of
the season * * * there was

REPORT.

IX. A peculiar stiffness in the
muscles of the face and
neck was often an early
symptom.

X. This would be followed by
local spasms,

XI. perversion of vision, &c.

XII. In some cases the initia-
tory symptoms were those
of a severe cold, with a dis-
position to paralysis of the
tongue and a portion of the
muscles of the face.

XIII. With this the respira-
tion would be difficult and
irregular, giving occasion
to fear a congestive attack
of the lungs.

frequently rather a univer-
sal coldness and inaction
than a real chill."

IX. " A kind of clonic spasm
of the muscles of the neck "
is mentioned by North
among the " more unusual
symptoms." — P. 15.

X. " Convulsions and spasms
occasionally attend the ac-
cess of the disease ; but
they are more frequent in
its later stages." — M. M.
Soc. Report, p. 123.

XI. " The powers of sight are
affected in various degrees,
from a slight dimness to
absolute blindness." — M.
M. Soc. Report, p. 123.
" Blindness in some, in oth-
ers double or treble vision."
— North, p. 15.

XII. " In the muscles of vari-
ous parts, paralysis has been
occasionally observed ; as
in those of one hand or foot,
and oftentimes in those sub-
servient to deglutition."
M. M. Soc. Report, p. 123.
"In some of Dr. Hale's cases
it is mentioned that the
tongue was protruded with
difficulty." The symptoms
enumerated as those of
"the most common mode
of attack," on page 54 of
Dr. Hale's book, will pass
for those of the severe cold.

XIII. " The respiration was
much and variously affect-
ed ; in general it is difficult.
Cough rarely occurs, and
the difficulty of respiration
has not commonly appeared

CEREBROSPINAL MENINGITIS.

XI Y. There was often tender-
ness at the nape of the neck
and along the spine early in
the disease.

XY. The skin was usually
moist, but hot.

XYI. The face was suffused,
often of a dusky hue, and
the features distorted in the
manner above mentioned —
the eyes congested and suf-
fused.

XYII. There was not for the
most part active delirium,
but perversion of intelli-
gence rather, and dulness
and indifference to outward
objects, from which condi-
tion the patient could be
roused and made to answer
questions consciously.

XYIII. The tongue had at the
first, a white creamy coat,
which in the course of the
disease, became yellowish
or brown at centre and base,

to arise from an inflamma-
tion of the lungs.'' — M. M.
Soc. Report.

XIY. Pain in the neck and
back are mentioned by au-
thors, but tenderness distin-
guished from pain is not.

XY. The old spotted fever was
described as having three
stages. In the first, Hale
says, the skin was dry with
a burning feeling. — P. 54.
In the second stage it was
warm, without that burning
heat, and moist. — P. 68.

XYI. "The face and eyelids
are often swollen ; and in
some cases the face is swol-
len and black like that of a
person strangulated. The
eyes " were " dull and
glassy or red and watery."
M. M. Soc. Report, p. 128.
" Redness and effusion of
the eyes," says North, p.
15. " Features dissolved,
with a loss of all character
and expression." — M. M.
Soc. Report, p. 124.

XYII. " The delirium is often
mild ; in some cases, how-
ever, * * * it produces a
fury which is scarcely to be
restrained." — Ibid. p. 1^3.
The Report does not say
whether the patient could
usually be roused so as to
give logical answers.

XYIII. "The tongue is usu-
ally moist and white through
the whole disease, when it
terminates within three or
five days. When it con-

REPORT.

more rarely dry and cracked
towards the close.

XIX. There was loss of ap-
petite,

XX. but usually not very
urgent thirst.

XXI. The heart's action was
irregular, sometimes tumul-
tuous, to which the pulse
did not always respond, be-
ing- mostly accelerated but
not strong, occasionally in-
termittent.

XXII. The bowels were regu-
lar, or inclined to diarrhoea
and costiveness by turns.

tinues longer the tongue
becomes darker colored,
yellow or brown. It is
sometimes clear and red."
—Ibid. p. 133.

XIX. "The appetite is di-
minished, but is not always
so entirely destroyed as in
most other acute diseases.'7
—Ibid. p. 133.

XX. " There is seldom any
remarkable thirst."— Ibid,
p. 133.

XXI. "Velocity of the blood
increased, with a very sen-
sible diminution of momen-
tum in the radial, while in
the carotid arteries it was
much augmented." Daniel-
son and Mann's Essay in
Dr. North's book, p. 90.
" The pulse like other symp-
toms was various, some-
times considerably full, but
generally very weak, quick
and irregular." — Dr. Wood-
ward's remarks in the book
of Dr. North, p. 113.

" They [the pulses] are
sometimes hard : more often
they are intermittent, and
irregular both in force and
frequency; they are remark-
ably variable, so that in the
course of an hour, and in-
deed in much less time, they
change from quick to slow,
from strong to feeble, and
vice versa. — M. M. Soc.
Report, p. 130.

XXII. The bowels, some au-
thorities say, were rather
costive than loose. Dr.
Hale says, "There were a

CEREBROSPINAL MENINGITIS.

XXIII. Petechia were not an
unfrequent manifestation —
in appearance almost iden-
tical with the true typhus
eruption, and like that seen
upon every part of the body
except the face — persistent
upon pressure, varying in
hue from the darkest aspect
of measles to that of the
true petechial spots imbed-
ded in the skin. Purpural
spots, abundant and of large
sizes, were sometimes pre-
sent, and were always a
grave symptom.

[Other American observ-
ers have noticed besides
petechia, efflorescences,
ecchymoses, vibices. Also
spots on the face.]

XXIV. There was no marked
tenderness of the epigastri-
um or abdomen.

XXY. In the cases of longer
duration there was in the
last stages sordes on the
teeth and lips,

XXVI. and involuntary evac-
uations of urine and faeces.

few instances of diarrhoea in
the commencement of the
disease, and it sometimes
made its appearance " later.
There was much more often
a tendency to costiveness
than to diarrhoea." — P. 93.
But on the whole, he says,
"the bowels showed very
slight marks of disease."
Page 92.

XXIII. The Committee of
1810 say the eruptions in
their spotted fever were not
constant, and varied from
red spots to purpura, pete-
chias, and vibices. An ap-
pearance like measles was
sometimes noticed. They
appeared on various parts
of the body and limbs. — M.
M. Soc. Report, pp. 135
and 136.

Dr. Strong says they were
also found upon the face.
He also says they did not
rise above the surface or
recede upon pressure. (Dr.
0. W. Holmes, op. cit.)

XXIV. "The bowels showed
but very slight marks of
disease.77 — Hale, p. 92.

XXV. Sordes not mentioned.
" When the disease con-
tinues longer, the tongue
becomes darker colored,
yellow or brown.77 — M. M.
Soc. Report, p. 133.

XXVI. In the comatose stage,
says Hale, " the urine and
faeces were^passed involun-
tarily.77—P. 15.

REPORT.

XXVII. The patients of ten die
without much symptoms of
exhaustion. [In several of
Dr. Upham's cases it is
mentioned that the patients
died without great exhaus-
tion. Yet in cases V., VI.,
XI., use is made of the fol-
lowing- expressions, viz.:
"exhausted," " exhaustion
almost amounting to col-
lapse," " collapsed." The
prostration in other report-
ed cases is as excessive as
in any of the epidemic of
1806-15. At any rate, all
observers will concur in pro-
nouncing the present epi-
demic one of decidedly
adynamic character.]

XXVIII. The decubitus was
mainly on the side,

XXIX. with the head not un-
frequently thrown back, the
neck rigid and stiff, a par-
tial opisthotonos.

XXX. There was uniformly
great restlessness and jac-
titation.

XXXI. As an accompani-
ment, and occasionally a

XXVII. " In whatever form
the disease commences,
there suddenly ensues great
prostration of strength. In
some instances the patient
is described as almost im-
mediately falling down un-
der the weight of the dis-
ease."— M. M. Soc.Eeport.

XXVIII. No mention of de-
cubitus found. In speaking
of the pain, the Committee
of 1810 say it is often con-
fined to one side of the body,
and the left side is more apt
to be affected than the
right.

XXIX. The Committee of 1810
speak of spasms " occasion-
ing the head to be drawn
back as in opisthotonos."
P. 129. Other instances of
occasional mention of this
symptom have been cited
above. But we should infer
that it was much less fre-
quently noticed in the old
spotted fever.

XXX. " Restlessness and agi-
tation."— M. M. Soc. Re-
port, p. 124.

XXXI. Inflammation of the
eyes I have found mention-

CEREBROSPINAL MENINGITIS.

sequel to the disease, iritis
was several times observed.

XXXII.

tis.

So also was synovi-

XXXIII. And in one instance
pericarditis.

XXXIII. The above are among
the more prominent and con-
stant symptoms, but there
was a considerable diversity
in the manifestation of the
disease during its progress,
whether towards a favora-
ble or fatal result ; in no
one case do I remember to
have seen even a majority
of those I have enumerated
present.

XXXIY. The duration of the
affection varied from a pe-
riod of less than thirty-six
hours, to that of three, four,
or six weeks, and even
longer."

ed, but without always dis-
crimation as to the part of
the organ affected.

XXXII. Analogous if not sim-
ilar to this are the following
statements. "In some cases
swellings have occurred on
the joints and limbs. These
have been very sore to the
touch, and their appearance
has been compared to that
of the gout."— M. M. Soc.
Kep., p. 135. North says,
" swelling like rheumatism
of the joints." — P. 15.

XXXIII. "Occasionally in-
flammation is also found
on the membrane covering
the heart, and lining the
pericardium." — P. 160, M.
M. Soc. Report.

XXXIII. " Every symptom is
not to be observed in every
case ; on the contrary there
is great variety in the symp-
toms, and it is said there is
great variety also in the
order in which they occur."
P. 127, M. M. Soc. Report.

XXXIY. "A few are taken
off suddenly in ten or twelve
hours ; others in twenty-
four, thirty-six, or forty-
eight hours, from the first
symptom of the disorder."
" By some of our corres-
pondents it is said that re-
covery from this disease has
been rapid and the subse-
quent state of the health as

30 REPORT.

good as usual. But the ex-
ceptions to these remarks
are certainly numerous." —
Pp. 126 and 135, M. M.
Soc. Report.

Of the fatal cases (which
were of relapse) in Hale's
practice, three were pro-
longed to the thirteenth,
sixteenth, and twenty-sec-
ond days respectively. The
cases of recovery he rarely
attended longer than four-
teen days. But the num-
ber of the sick and the dis-
tance between them, com-
pelled him to leave them
early in the convalescence.

An anomalous symptom described sometimes as marking
the invasion of the old spotted fever, we are not cognizant
of as occurring in our present epidemic, viz. : the access by
a sudden pain in a joint, in a finger or toe, or a sensation
like the stinging of a bee, &c, heretofore mentioned.*" But
the most important difference between the epidemic of 1806
-15, and that of to-day, seems to be that opisthotonos does
not appear to have attracted the attention of the older ob-
servers as a frequent and striking phenomenon. This differ-
ence will probably not be considered fatal to the identity of
the two epidemics, since, at most, it shows only that the
spinal did not share the affection of the cerebral meninges
in the older one, and does not, it is fair to presume, prove a
difference in its essential nature from that now prevailing.

Relapses occurred in 1806-15; and though Dr. Upham
does not mention them, there have been many instances of
them in the present epidemic.

* Stinging pains in the arms and legs have been lately reported, but not as the
first symptoms.

CEREBROSPINAL MENINGITIS. 31

We now quote Dr. Upham's summary of the anatomical
lesions, which we think corresponds remarkably with that we
have previously given, as compiled from the report of the
Committee of 1810, even to the thoracic and abdominal
complications.

" The anatomical lesions in the cases examined were con-
fined principally to the brain and spinal cord. When
death took place early, within two or three days, there was
commonly opalescence of the upper surface of the cerebrum,
seemingly in the subarachnoid fluid; an increased vasculari-
ty of the membranes of the brain and spinal cord, affecting
the pia mater especially ; a large increase of serum in the
subarachnoid space and ventricles, clear or turbid, and mixed
with flocculi of lymph, with, as often as otherwise, even in
cases of the briefest duration, an abundant exudation of
thick, yellowish, apparently semi-organized lymph on the
base of the brain and medulla oblongata. Conjoined with
these phenomena, there was, in such cases, more or less
passive congestion of the lungs ; increase of the pericardial
fluid, and occasional engorgement and enlargement of the
liver and spleen."

Correspondence between the foregoing and " Epidemic Cerebro-
spinal Meningitis " as observed in France.

We cannot forbear to translate, here, from Valleix's Guide
du Medecin Praticien (Vol. IV. pp. 540, 541), the greater
part of his graphic description of the morbid appearances in
what he denominates " meningite cerebro-spinale epidemique"
We would premise that his statement of the symptoms cor-
responds so completely with those of our present epidemic
of spotted fever or cerebro-spinal meningitis, as (taken
together with the post-mortem appearances) to leave no doubt
that we, in this country, are now at least dealing with a dis-

32 REPORT.

ease which has been observed in different parts of France
for upwards of twenty-six years, and which has been most
thoroughly described by Talleix under the name of epidemic
cerebro-spinal meningitis.

" The anatomical lesions/' says Valleix, "in this grave mala-
dy, have, as would be expected, been studied with the greatest
care. The principal lesions have been found in the pia
mater of the brain and spinal cord. Yet, all observers
have reported a certain number of cases in which these le-
sions were very slight or inappreciable. Thus in some sub-
jects there were found in the cerebro-spinal membranes
nothing but injection more or less intense, a little limpid
serosity, or, on the other hand, marked dryness without in-
jection, but all these cases were from among those in which
the meningitis had struck down the patient as by a thun-
derbolt, and in which by consequence the pathological
alterations had not had time to develop. In other cases
there were found in the meshes of the pia mater either a
liquid which was yellowish (or yellow) and turbid; or thick
perfectly well marked pus j or else a denser substance, of a
pseudo-membranous appearance, opaque, yellowish, dense,
of a thickness of 3 to 6 millimetres, and similar, according
to an expression of M. Tourdes, to a layer of butter spread
over the surface of the brain.* It is especially along the
course of the vessels that this morbid production shows itself,
and in fact, so long as it is in small quantity, it can only
exist at these points and ramify with the veins. At other
times there are seen here and there flat and otherwise
uneven masses, of variable size, and composed of the same
substance. Finally, this morbid product has been seen so
abundant that it entirely enveloped the cerebrum and cere-
bellum. Ordinarily, neither do this layer nor the purulent

* See the summary above given of the morbid appearances in the epidemic of
1806-15.

CEREBRO-SPINAL MENINGITIS. 33

masses show themselves except on the surface ; but some-
times they penetrate with the pia mater even into the depths
of the convolutions. Pus is not found in the cerebral ven-
tricles save in a limited number of cases (half, according to
the researches of M. Tourdes) : sometimes these cavities con-
tain only limpid serosity. Purulent infiltration of the choroid
plexus, and superficial softening of the walls of the ventricles
have also been seen, but these lesions are only of secondary
importance.

" All points of the cerebellum and cerebrum are liable to
these alterations : but they have been found almost con-
stantly on the cerebellum, frequently at the summit and base
of the cerebrum, more rarely on the pons Varolii, &c.

"In the spinal canal the lesions are similar and occupy
likewise the pia mater. * * * * In the brain and spinal
marrow injection and partial softenings are found. But,
although a few symptoms observed in certain cases are re-
ferable to these lesions, the latter are only accidental in the
disease under consideration, which is perfectly characterized
by those we have just described.

" The alimentary canal has presented a few traces of slight
inflammation in quite a number of cases ; but never altera-
tions of Peyer's patches, which have been found merely a
little prominent. Brunner's glands are frequently enlarged
through a great extent of intestine, but never ulcerated.

" The lesions found in the other organs need not delay us
here, since they are rare and variable, and are considered
only the result of complications. Suffice it to say, that there
have been noticed inflammation of the lungs, of the pleura,
of the joints, &c."
5

34 REPORT.

HISTORICAL NOTICE OF THE DISEASE.

We have now compared the symptoms and anatomical
lesions of the spotted fever of 1806-15 with those of the
"spotted fever/' otherwise called " cerebro-spinal meningitis"
at present prevailing. We have also assumed to identify
our epidemic with a disease which has been observed abroad,
and there described under various names, among the most
prominent of which is " epidemic cerebro-spinal meningitis."
It is therefore in order in this place to say the few words
remaining to be said of the history of the disease, before
proceeding to the special work of collating its statistics for
Massachusetts.

Discussions may be found in the works of various writers
as to whether or not the disease under consideration be the
same with certain epidemics described by the older nosolo-
gists. Into these discussions we do not propose to enter;
we will merely mention that a French writer, M. Tourdes, has
examined the question, and going back to the earliest period
of medical history, has passed in review the different epi-
demics capable of being assimilated to cerebro-spinal menin-
gitis. Valleix, in criticizing the narrative of M. Tourdes,
remarks that it contains a number of facts which, without
much forcing, might be considered as examples of epidemics
of cerebro-spinal meningitis similar to those which have
come under the eyes of observers in our clay; but that it
adduces other facts which cannot be so regarded, and can
only be looked upon as epidemics of typhoid or typhus
fever. He adds that in all these cases there is too great
incompleteness of description, and deficiency of anatomical

CEREBROSPINAL MENINGITIS. 35

investigation, to enable us to accord much importance to
these historical researches.

The disease in question, denominated by the Italians, it is
said, " tifo apoplettico tetanico" is sometimes described in
Germany as "cerebral typhus." Among the Germans it
is also popularly known as " flecken fieber" which means
literally " spotted fever " ; and again, on account of the
painful contractions of the muscles of the neck, as " gcnick-
Tcrampf." Its usual scientific denomination in Germany is
cerebro-spinal meningitis.

It is stated to have been first clearly recognized, at
least in later times, at Geneva in 1805 (about the same
epoch at which it broke out in New England) ; afterwards
in different localities on the Continent, in 1806-7, 1811,
1813, 1814, 1815, 1816, and 1823.— (American Journ. Med.
Sciences, July, 1864, p. 93.)

Valleix * states that " epidemic cerebro-spinal meningitis"
invaded France some little time before the year 1839, show-
ing itself first at Bayonne, Narbonne, Foix, Bordeaux. In
1839 it reigned at Rochefort, and almost exclusively in the
prison for galley slaves, being taken there, at first, for typhus,
but afterwards recognized as " epidemic cerebro-spinal me-
ningitis." Later it raged in localities very diverse. A little
while before the advent of the cholera in 1849, there were
epidemics at Orleans, and Paris. In France the epidemics
have shown themselves almost exclusively among soldiers
(and those principally new recruits), which amounts to say-
ing that its subjects were there mostly adults of the male
sex, and from twenty to thirty years of age. At Rochefort,
however, the affection attacked in the prison ("Bagne")
principally middle aged prisoners, while in the town it raged
mostly among individuals of less than twenty years of age,

* Guide du Medecin Praticien, Vol. IV., p. 529.

36 REPORT.

almost exclusively males. Yalleix could not discover that
either climate or season had any special influence upon the
malady.

In Leipzig there were cases of the disease in July, 1864,
followed by more in September and August. Prof. Wunder-
lich states that he had not heard of the malady in Germany
before that time since 1849.

In Ireland, Dr. Darby, of Bray, first called the attention
of the profession to the disease, having observed it in the
Rathdown Union Workhouse, during the months of January,
February and March, 1846. It appeared in the South Dub-
lin Union Workhouse about the same time • and in the Belfast
Workhouse in April and May of the same year, thus de-
claring itself in three different localities in Ireland, where it
was described by Dr. Robert Mayne, in the Dublin Quarterly
Journal of Medical Science for August, 1846, under the
name of " cerebro-spinal arachnitis." Dr. Mayne says, "Its
pathology seems to have been nearly uniformly the same,
wherever examined. The serous membrane covering the
brain and spinal marrow has been found invariably the seat
of extensive inflammation,* and unlike the more ordinary
forms of arachnitis, the spinal arachnoid suffers much more
severely than the cerebral." For the rest, the anatomical
lesions corresponded with those given above from Yalleix,
Dr. Upham, and our Committee of 1810. The invasion of
the disease was in most instances sudden. The Irish cases
were generally fatal — some in 48 hours, most of them about
the fourth day, while a few lasted a fortnight or three weeks.
No mention is made in Dr. Mayne's report of petechias or
other spots. The above cases were nearly all of boys wider
twelve years of age.

As we have said, the paper of Dr. Upham, published in
1863, in the Boston Medical and Surgical Journal, in the
number for April 9th et seq., was one of the first to draw

CEREBROSPINAL MENINGITIS. 37

the attention of the profession to the prevalence in this
country of the present epidemic. But Dr. Gerhard, in an
article presented to the College of Physicians of Phila-
delphia, April 1st, 1863, and printed in the American
Journal of Medical Sciences for the following July, formally
introduces the subject to the medical public with a notice of
recent cases of which he had been cognizant, in and around
Philadelphia, where, says Dr. Gerhard, the disease was at
that time entirely novel. Since then many cases have been
reported in that place. Dr. Gerhard states the subjects, of
whom he was cognizant, to have been mostly from 15 to 25
years of age, and that more females were affected than males.

The evidence, however, of subsequent reporters, brings to
light the occasional occurrence of the disease (since the epi-
demic of 1806-15) in diverse places in this country during
a period of a score of years previous. For instance, Dr.
Drake says it was first noticed in the " Interior Valley of
North America " about the same time it attracted attention
on the Continent of Europe, that is, in the year 1840-41.

In 1 842 there was an epidemic of it in Rutherford County,
Tennessee.

At a meeting of the College of Physicians of Philadelphia,
April 6th, 1864, Dr. Gilbert stated that he saw at Gettys-
burg, "in 1844, or thereabouts," two cases, in both of which
there was sudden attack by chill, great prostration of the
vital powers, with " cerebro-spinal complication," stupor,
coma, and death ; the first case in twelve, the second in sixty
hours. Another case was seen by Dr. Gilbert in Philadel-
phia, in 1846, in the person of an adult male who died in
ten hours after the attack. Of the autopsy made in this
case, Dr. Gilbert very briefly says, that the most remarkable
condition discovered was a spotted appearance of all the
serous surfaces of the chest and abdomen, no statement being
made as to whether or not the head was opened.

38 REPORT.

In the autumn of 1845, and the following winter, it was
at Mt. Vernon and other places in Southern Illinois.

From January to March, 1 847, it was in Vicksburg, Mis-
sissippi.

In February, and the spring of 1847, it occupied Benton -
ville and Union City, Arkansas.

In January and February, 1847, a regiment of United
States recruits from Mississippi, while in the vicinity of
New Orleans, suffered severely from it.

In February, 1850, it prevailed in New Orleans.

In the" winter and spring of 1848, the disease prevailed
in Montgomery, Alabama, under the name of " epidemic
meningitis."

At the last mentioned place the post-mortem appearances
described were similar to those of the Committee of 1810,
except that in the cases at Montgomery the spinal meninges
were found to be affected. Dr. Ames reports that there
were in Montgomery 250 cases out of a population of 4,000,
or 6 J per cent. Of 85 cases described, there were 22
whites and 63 blacks, the black population out-numbering
the white. Of the whites attacked there were 10 males and
12 females; of the blacks, 36 males and 27 females. Dr.
Ames gives the following table : —

Ages.

Whites.

Blacks.

Up to 6
" 10

years,

l c

1
6

" 21

" 31

a 41

" 51

Above 50

22 63

At the South, says Drake (On the diseases of the Interior
Y alley of North America), the affection attacked town and

CEREBROSPINAL MENINGITIS. 39

country, but not the larger cities, with the exception of New
Orleans. The subjects were mostly children and young
persons, but no age was exempt.

At a meeting of the Boston Society for Medical Improve-
ment in 1849, Dr. Joseph Sargent, of Worcester, Mass., re-
ported several cases of " cerebro-spinal meningitis," as he
termed them, having the characteristic symptoms and ana-
tomical appearances of the disease we are discussing. Those
cases were instances of an endemic,* which prevailed in the
towns of Millbury and Sutton (adjoining each other in the
central part of Massachusetts), during the month of March,
1849. Perhaps Dr. Stille refers in part to these cases
when he says the disease appeared in Massachusetts and
New York in 1850 to 1851.

According to Dr. Stille the present epidemic took its rise
in the central and western parts of New York (where it pre-
vailed extensively), in the year 1857, and thence travelled
southward at least as far as North Carolina. This state-
ment needs to be modified, we find, in two points. The
disease broke out in April of the same year, 1857, in the
town of Becket, in Berkshire County, Massachusetts. Thus,
it can hardly be said to have taken its origin in New York.
Again, it has been heard from not only at the South, but in
other directions — North, East, and West. If all the facts
were known, perhaps Dr. Stille's statement would have to
be still further modified. For example, are we sure that
the first cases have even yet been reported ? From our ex-
perience in this State, showing the small number of cases
which have been published in comparison with that which
has come to light upon investigation, we infer that the infor-
mation before the public of the epidemic at large, is very
partial and imperfect. The following facts, however, illus-

* The word endemic is used here in the sense of a limited epidemic.

40 KEPORT.

trative of its progress and behavior, we have culled for
record here.

In the year 1858, cases were reported by Dr. Craig, to
have occurred at Churchill, N. Y. In six of these cases,
autopsies were made, at all of which were found inflammatory
lesions of the meninges.

In the winter of 1861-62, there was an epidemic of the
disease in Livingston County, Missouri, breaking out first
among the soldiers in Chillicothe.

We find that in the fall and winter of 1863-64, it pre-
vailed among the negroes in Memphis, Tennessee, mostly in
subjects from 10 to 14 years of age, of both sexes; though
many adults were attacked, and some very old negroes.
The first winter, Dr. Morrill, the reporter, heard of no case
of recovery. It occurred among the negroes in Maryland,
in 1864.

It has extended its ravages, as we have said, in other
directions. In the winter and spring of 1863, it raged ex-
tensively and very fatally in Northern Indiana. In Cam-
bridge, Ohio, it prevailed to an alarming extent in 1863.
Cases are also reported in Newark, Ohio, from Nov. 30,
1863, to January, 1864; and at Mechanicsburg, Ohio, in
February and March, 1865.

At the anniversary meeting of the Illinois State Medical
Society, in 1864, Dr. McVey read an account of its preva-
lence in Morgan County, Illinois, in 1863-64. On the same
occasion, Dr. J. Adams Allen read an excellent paper on an
epidemic of it prevailing, as he says, for some years pre-
vious, throughout Illinois, " and many of the North-western
States."

In the months of January, February, March and April,
1863, there were seven cases among the midshipmen billeted
on the school-ship in the harbor of Newport, Rhode Island.
In the early months of the year 1864, it prevailed at Brat-

CEREBROSPINAL MENINGITIS. 41

tleboro', Vermont, in the military camp ; also in the village,
and in isolated farm-houses for some miles around.

It will be our duty to report on its incursions in this
State in another part of this paper.

It may be interesting to note that the Surgeon of the Flag-
ship, " The Blackhawk," of the Mississippi Squadron, reports
a case on his vessel in May, 1864, in a newly enlisted man,
the only case in the Squadron. In this case the meningeal
lesions were very marked on post-mortem examination.

Still more interesting, it seems to us, is the following fact.
In the April number of the American Journal of Medical
Sciences for 1865, Dr. Burns reports, among a number of
cases of recovery in Philadelphia in the spring of 1864, two
cases of what he claims to have been instances of the disease
in question during pregnancy, thus repeating the experience
of observers of the epidemic of 1806-15. Both patients
were at the sixth month of gestation, and went their full
time. One of the infants died of diarrhoea, in four months
after its birth, the other in ten months, of " pulmonary
catarrh."

Cases have been reported, in which sore throat was an
early symptom; corresponding, like the cases just men-
tioned, with the observation of one of the reporters of the
old spotted fever.

In relation to the prevalence of the disease in military
camps and barracks, the writer addressed a letter to the
Surgeon General of the United States, and received through
Assistant Surgeon General Woodward a prompt and very
kind reply, from which we give the following extract : "lam
directed by the Surgeon General to say in reply to your com-
munication of the 8th inst., that spotted fever, otherwise term-
ed cerebro-spinal meningitis, has prevailed to a considerable
extent among the troops in camps and barracks during the
present war. Recruits have not escaped, and those have
6

42 REPORT.

especially suffered who were crowded in barracks and draft
rendezvous." The records of the Surgeon General's office
are not sufficiently made up to furnish a report of the com-
parative number of military establishments invaded by the
disease, or of the proportion of recruits attacked by it.
But these points will probably be published in official docu-
ments.

CONCLUSIONS FROM THE PRECEDING SKETCH.

To trace the course of the " spotted fever " in all its rami-
fications, even in this country alone, would be an arduous, if
not an impossible undertaking, and is not our province.
But, from the very brief sketch we have given, certain lessons
may be derived, as follows, viz. :

I. The medical history of the Rebel States has been, dur-
ing the war. to a great extent a sealed letter to us. But
the writer remembers to have read, in 1864, a newspaper
account of "a new disease " in one of the Gulf States, with
a brief but very graphic summary of the symptoms, which
tallies in most respects remarkably with those now familiar
to us as symptoms of spotted fever, or cerebro-spinal menin-
gitis. Of the large portion of the country, however, within
our reach, North, East, and West, no extensive region seems
to have been exempt.

II. From the fact mentioned by Dr. Jackson, that he had
met with cases occasionally since the epidemic of 1806 to
'15, and from the cases cited by Dr. Gilbert — two at Gettys-
burg, about 1844, and one at Philadelphia, in 1846 — we
perceive that there have been sporadic cases.

CEREBROSPINAL MENINGITIS. 43

Endemics of the disease we have spoken of, as that of Dr.
Joseph Sargent, in 1849, in this State; that of Dr. Ames, at
Montgomery, Alabama, in 1848; and others.

Finally, we say the disease has prevailed as an epidemic,
since 1857. Thus, the disease in question has prevailed
sporadically, endemically, and epidemically.

III. Is this a military disease ? In France, it has been
declared so, since it there confined itself mostly to soldiers,
among them particularly affecting new recruits. But, in
Ireland, the reports given of it were from work-houses. In
this country, military camps and barracks have often furnish-
ed the conditions requisite to invite its presence, since we
are told by the Surgeon General it has prevailed in them
" to a considerable extent." Its invasion of the regiment of
United States recruits in Mississippi, in 1847, three years
before it appeared in New Orleans, and ten years before it
is supposed to have become epidemic, is an interesting fact.
But while it is well known that many military establishments
have escaped its incursions, private dwellings have, to a
large extent, been visited with its baleful influence. Its
course in the town of Brattleboro', Vermont, in 1864, may
be taken as an epitome of its general behavior. It invaded
the military camp for recruits on the outskirts of the town.
There, the writer was told by Surgeon General Phelps, the
chief medical officer in charge, that the opisthotonos was
observed in a very intense form, the body of the patient
being bent almost into the form of a semicircle. About the
same time, it appeared in the village and, in the distant farm-
houses. A boarding school for boys, at the extremity of the
village opposite to that where the camp was located, was
represented by a single case.

Spotted fever, then, is clearly not exclusively, or par excel-
lence, a military disease. To what proportionate extent mil-
itary establishments, and particularly recruits are liable to
it, remains to be ascertained.

44 REPORT.

IV. That the disease is not one of large cities, compara-
tively, is the general result thus far.

V. In France it is stated that neither climate nor season
has been found to exert any influence upon the disease. In
Leipzig, an epidemic described was in the summer. But in
Ireland and this country, by far the greater number of cases
hitherto reported have been in the first five months of the
year.

VI. The evidence from all sources has been very gen-
erally in favor of the non-contagiousness of the disease.
Facts strongly in point, are the single case in the boarding-
school at Brattleboro', Vt., and the single case in the Mis-
sissippi Squadron.

VII. As to its choice of sex, the disease has shown great
variation in different places. In the Irish work-houses it
confined itself almost entirely to boys. In this country it
has shown a preference in some places for the male sex,
while in others more females than males have been attacked.

VIII. The Hack race in this country have not escaped the
disease.

IX. In different sets of cases there is wide variation in
the character of the spots, and the frequency of their occur-
rence.

X. The fatality of the disease has varied greatly in the
different reports of the disease which have been given ; e. g.,
the first winter of its visitation of Memphis, all the cases
were fatal, while at Newport, 3 out of 7 recovered. We
will remark here, that in the present epidemic, as in the old
spotted fever, it has been noticed that those cases which
proved fatal were generally so in a few days, or hours.

XI. The fact has been stated of the epidemic of 1806 to
'15, that relapses sometimes occurred. They have also taken
place in the present one. But, in the latter, unlike what
obtained in the former epidemic, the instances of which we
are cognizant have been often fatal.

CEREBROSPINAL MENINGITIS. 45

XII. The present epidemic tallies with the old one in that
cases of recovery from the disease during pregnancy have
been related.

XHI. Finally, to sum up, the disease has shown great
apparent capriciousness in its predilection for, or avoidance
of military establishments ; in its choice of sex ; in the vary-
ing frequency of the occurrence of spots ; in the character
of the spots (we may add also by parenthesis, in the groups
of its symptoms present in different individuals) ; in fatality;
in liability to relapse.

It has been generally consistent with itself in the matter
of contagion ; and in prevalence in towns and the country
rather than, or quite as much as, in large cities. It has
shown, also, a frequent if not general preference for the
earlier period of life.

Autopsies, in this disease, have not been numerous. Of
those reported, almost all have given appearances within the
cranium similar to some or other of those described above
by Dr. Upham and others.

Exceptions, however, are alleged, upon which are founded
by some the theory that the essential pathology of the dis-
ease is not in the meningeal inflammation. Thus Dr. Levick,
in the July number of the American Journal of Medical
Sciences for 1864, p. 136, gives the following instance.

Case VI. [The] little patient, eighteen months old, was
perfectly well on retiring to rest on the previous night. At
one o'clock she awoke and complained bitterly of her head.
At 9, A.M., she presented the following appearance : The
skin uniformly and finely mottled, of a purple hue, with
here and there a few isolated spots of a deeper purple.
Eyes slightly ecchymosed, presenting a dull, stupid, and at
times an astonished appearance; pulse 60. Carbonate of

46 REPORT.

ammonia given, and the hot bath and turpentine used exter-
nally. Child died at 3, P.M., same day. The autopsy was
most carefully made at 4, P.M., next day, by Dr. Packard,
in the presence of Dr. Fricke, Mr. J. C. Warren and myself,
and presented the appearances enumerated below.

EXTERIOR.

Decomposition of the walls of the abdomen, which are of
a green color. The surface of the body universally mottled ;
vibices on the knees, petechia? on the legs.

HEAD.

On removing the calvaria, a large ecchymosis was found
under the pericranium near the sagittal suture. The vessels
of the dura mater were filled with dark fluid blood, which
could readily be pushed aside by the handle of the scalpel.
The substance of the brain and of the medulla oblongata
was natural in its appearance and consistence. There was
no effusion in the ventricles, and the most careful examina-
tion failed to detect the slightest evidence of inflammatory
exudation.

ABDOMEN.

Blood fluid in the mesenteric veins. The intestines were
everywhere dotted with minute extravasations of blood, both
on their outer and inner surface. Similar ecchymoses were
found on the bladder, in the kidneys, and on the diaphragm.
Spleen healthy, the Malpighian bodies prominent. Mesenteric
glands enlarged: the solitary glands largely developed;
Peyer's glands unaffected.

THORAX.

Ecchymoses on the diaphragmatic pleura. The lungs con-
tained large quantities of fluid blood. The left ventricle of
the heart contained two soft coagula, about the size each of

CEREBRO-SPINAL MENINGITIS. 47

a pea. In the right heart, the blood was thin and fluid,
looking not unlike claret wine. There were no coagula in
the right side.

Case VII. Dr. Levick, also, in the American Journal of
Medical Sciences for July, 1865, reported a case which died
in twelve hours. The patient, a woman, was covered with
spots. There was no pain in the head, no opisthotonos.
At the autopsy, the meningeal vessels were filled with black
blood. There were no traces of inflammation in the btain or
its membranes. The liver was congested and fatty. There
were blood stains on the pleurae, stomach, intestines, pan-
creas, uterus. In the ovaries were several vesicles filled
with black blood. A few spots were seen on the bladder,
many on and in the kidneys.

It will be noticed that in the accounts of the autopsies in
these cases, though it is said there were no traces of inflam-
mation, yet it is not specified whether or not there were
opalescence, or preternatural dryness of the meninges. We
shall refer to this point again.

TREATMENT.

As to the various modes of treatment tried in this novel
affection, there is very little satisfactory to be said. In the
British practice, bleeding and mercury were resorted to. In
France, also, as mentioned by Valleix, bleeding was among
the remedies employed. Yenesection has been tried there
to a great extent, and with results less satisfactory to the
criticism of M. Valleix than to some of those who have used

48 REPORT.

it. Cold applications to the head have rather disappointed
the expectations which have been formed of them. Results
have not been in favor of mercurials. Blisters have been
much used, but no evident advantage was derived from them;
on the contrary, they often augmented the suffering of the
patient, without ameliorating any symptom. Sulphate of
quinine was tried also, but given for the purpose of conquer-
ing the affection itself; it had no real success. Administered
during convalescence, however, with a view of rousing the
appetite and hastening the recovery of strength, it was found
to be of considerable utility.

Some practitioners in this country have thought that
benefit was derived from quinine in their hands ; but Dr.
Upham's observation of it at Newbern, was, like that of
Yalleix, unfavorable.

One remedy alone Yalleix feels authorized specially to
recommend, and that is one which practitioners have been
timid in using in cerebral inflammation, viz., opium. He
says opium in large doses is the only remedy which has
been administered with any confidence, and which appeared
to exert any real influence over the disease. The dose of
this drug which has been employed with apparent success,
is two or three decigrammes and sometimes more, in twenty-four
hours; the decigramme being equal to 1.544 grains Troy
weight.

Dr. Atlee tried opium at St. Vincent's Home in Philadel-
phia, an institution for young children, the patients varying
from two to four years of age ; the usual dose for them being
one-twelfth of a grain of the extract. Of nine patients at
the Home, four recovered and five died. One of them was
a Sister of Charity in attendance. She recovered. The
dose for her was one-fourth of a grain of the extract of
opium every three hours. The results here were on too
small a scale, of course, to be decisive.

CEREBROSPINAL MENINGITIS. 49

In the epidemic of 1 806-1 5, also, opium was used by
some practitioners who claimed for it much success.

Inhalation of ether was tried in France, with apparent
benefit, as a sedative.

Bleeding has been tried in this country, in the present
epidemic, but not, we believe, with very encouraging results.
Among other remedies, quinine, already mentioned, ergot,
permanganate of potash and hydriodate of potassa, have been
reported. There is a general tendency toward a supporting
and moderately stimulating treatment.

SPOTTED FEVER, OR CEREBRO-SPINAL MENINGITIS
IN MASSACHUSETTS SINCE 1815.

Sporadic Cases.

That sporadic cases have occurred in Massachusetts has
been already mentioned, Dr. Jackson having seen such
occasionally since the epidemic which terminated in 1815.
Perhaps, also, the two cases given in the account of the old
spotted fever, which occurred in Brookfield, in 1816, should
be classified under this heading.

The Endemic in Millbury and Sutton, in 1849.

We have already alluded to an endemic (as we call it) in
this State, reported by Dr. Joseph Sargent, of Worcester.
It attacked the towns of Millbury and Sutton, in Worcester
County, in March, 1849. Millbury adjoins Worcester on
the South-east, and Sutton forms the South-eastern border of
Millbury. Of the first sixteen cases within a circuit of four
7

50 REPORT.

miles of a country not very thickly settled, there was no
recovery that could be " relied on." Of twelve others sub-
sequently reported to Dr. Sargent, by Dr. Rawson, only the
first two died. Dr. Rawson, strange to say, depended
mostly on bleeding and purging — not hesitating to bleed
even in the cold stage. Death occurred in one instance of
the first sixteen cases, in six hours from the attack : in three
cases, within twenty-five hours ; and in most cases, within
four days.

In Millbury all were males but one, in Sutton there were
three females at least ; thus making four females or upwards
out of the sixteen cases. In Millbury the disease was, for
the most part, within a few rods of the Rlackstone river.
In Sutton, the cases were in various parts of the town, high
and low. The Blackstone river skirts the town of Sutton
on the North-east. In each of the two towns is a large
pond or lake.

We here give, from the Records of the Boston Society for
Medical Improvement, the following abstracts of those of Dr.
Sargent's cases in which autopsies were made. We quote
the reports of the autopsies in full.

Case YIII. E. L., aged 55, scythe maker in Millbury.
Went to his work well at 7, A.M., March 26th, 1849, and
returned at 8, A.M., complaining of " aching in his bones."
There was headache during day, becoming worse in after-
noon. Passed the night in a comfortable quiet sleep.
Awoke at 7 o'clock, on the 2 7th, with a very severe head-
ache, soon becoming intense. Had a chill at 10 J, A.M.
Pulse 85, apparently full, but easily compressed. Respira-
tion not labored or hurried. Skin universally flushed, hot,
dry ; greatest heat about head. Pupils equal, moderately
dilated, contracting to light. The patient seemed to be
partially conscious. Being asked to put out his tongue,

CEREBROSPINAL MENINGITIS. 51

would protrude it, and not retract it. Did not seem to be
conscious of any pain — mistook morning for evening, and
repeated the mistake when corrected. His tongue was dry,
glossy, very red. At 1, P.M., a purgative having acted, the
skin was universally pale, and cold, especially at extremities.
Pupils contracted — obedient to light. The patient seemed
entirely insensible to what was going on, talked incoherently,
blowing the bellows, fishing, &c. Pulse 100, very small.
At 5, P.M., was in great and almost constant jactitation —
no rigidity. Died at 2, A.M., sixty-six hours after the pro-
bable invasion of the disease.

The treatment was by purgatives j calomel, with Dover's
powder, and counter-irritation.

Post-mortem Examination thirty hours after Death.

The body was mottled by large ecchymoses. Two to
three inches of adipose substance over abdomen, and nearly
as much over thorax. Viscera of thorax and abdomen, ex-
amined carefully, present no abnormal appearance. Lungs
healthy and crepitating, valves of heart normal; spleen
small, liver and kidneys of usual size and appearance. All
the abdominal organs inlaid in adipose substance ; no eleva-
tion of Peyer's patches.

Upon opening the cranium, there was no unusual adhesion
of the dura mater, which presented its ordinary appearance,
and preserved its polish on the arachnoid side. Under the
cerebral arachnoid, over the upper surface of both hemispheres,
was seen a whitish deposit, as of purulent matter. On at-
tempting to remove the arachnoid, the pia mater came with
it, the two adhering so closely as not to admit of separation ;
and the purulent deposit was between them. On both sides
of the cerebellum there was a considerable intermeningeal
deposit of pus, and lymph also. The membranes having
been detached from the cerebrum, it had not its usual white-

52 REPORT.

ness and polish, but was dull and punctated, like the inside
of a strawberry, and, on being scraped, was found to be
somewhat softened. The cut surface presented an unusual
number of red points. The cerebellum seemed healthy ; no
unusual fluid in ventricles. No pus seen along medulla
oblongata.

The spinal marrow being exposed from the front, at com-
mencement of dorsal vertebra?, a considerable deposit of pus
and lymph was found without softening of the marrow.

Case IX. A. C, set. 47, farmer and teamster — usually a
healthy man. Complained of " aching of the bones," March
3d, 1 849, which was much increased on the 4th. Slept well on
the night of the 4th, but woke early on the 5th, complaining
of severe headache, backache, "aching all over." At 8
o'clock was found, by his medical attendant, lying on the
side of the bed, his pupils much dilated, knowing nothing —
with entire loss of muscular action, so that his hand if raised
would drop. Pulse 80, and easily compressed. Head not
very hot, general heat natural. Respiration not labored.
He was lying like a man in a quiet sleep. Resisted in a
dogged manner all medical and other interference. He was
restless, getting up, walking about, and sitting down like a
man with a stiff neck. Passed into a half conscious state,
which he maintained, answering questions accurately for a
moment, and then talking to himself or exclaiming with pain,
till about the tenth day, when he sank into a typhoid state,
with rigidity and opisthotonos. Then came subsultus tendi-
num, picking at the bed-clothes, and involuntary evacuations
of urine. He died on the 13th day of his illness. The
treatment was similar to that of the preceding case.

Post-mortem Examination.
The body was large, limbs rigid. On opening the head,

CEREBROSPINAL MENINGITIS. 53

the veins of the meninges were found to be turgid, with dark
blood. There was no unusual serous fluid below the arach-
noid, but here and there, between the convolutions of the
cerebrum, there was a whitish deposit, which, on the removal
of the membranes, was found to be between the pia mater
and the arachnoid, dipping down between the convolutions,
and being of the consistence of lymph.

The membranes were easily detached from the cerebrum,
leaving its surface white, polished, and of the ordinary firm-
ness. It is rare to see the cerebral substance harder ; the
consistence was uniform ; and the cut surface presented no
unusual red points. The right lateral ventricle was distend-
ed with a serous fluid, containing flocculi of lymph and pus.
The choroid plexus was red, like the comb of a cock. On re-
moving the right hemisphere of the cerebrum from the skull,
the anterior lobe presented an inter-meningeal deposit of pus
and lymph, of an inch in irregular diameter immediately over
the orbit. The sella turcica, was covered in like manner,
and the optic nerves enveloped — the nerves themselves pre-
serving their ordinary consistence.

The right hemisphere having been removed, the deposit of
pus and lymph dipping down between the convolutions on
the other side, in situ, was quite remarkable. Neither tu-
bercles, granulations nor ramolissement were found any-
where. At the base of the cerebellum and about the medulla
oblongata, there was a good deal of lymph with abundant
pus also; and this could be seen along down the spinal
marrow as far as the eye could penetrate, all being bathed
in pus. The spinal marrow was then exposed in front from
upper dorsal vertebra to sacrum, and everywhere there was
abundant pus between the pia mater and the arachnoid,
especially on the posterior part, so that it could be spooned
out. The spinal marrow itself and the nerves were quite
firm. The right sciatic nerve, exposed by an incision through

54 KEPORT.

the gluteal region, presented nothing abnormal. The lower
lobe of the right lung was in a state of red hepatization —
florid, solid, heavy, friable, containing no air. Lungs other-
wise entirely healthy. Some subsidence posteriorly.

Spleen small ; pancreas, kidneys and liver presented no-
thing unusual ; intestines, examined throughout their whole
track, presented nothing abnormal ; no development of Pey-
er's patches ; the bladder was distended with urine.

Case X. The case was of a child in Sutton, aged five
years, which died eight hours after invasion of the disease.
There was nothing abnormal found in the examination, ex-
cept a turgid state of the meningeal vessels, and a pulpy
condition of the spinal marrow. The body was covered
with purple petechise, a line or so in diameter, and not
raised. The same were found on the peritoneal face of the
stomach, and were confined to the peritoneum.

The patient in Case VI. lived the longest of all the fatal
cases — thirteen days. The invasion in both V. and VI. was
less sudden than frequently occurs. Case VII. seems to
have been an instance of slight anatomical lesion attributable
to the rapid termination.

Dr. Terry, now of Connecticut, but formerly of Sutton,
Mass., gives us the following information in regard to his
cases in that town in 1849.

Dr. Terry had six cases from the 26th of February to the
27th of March, 1849. Of these, four were males, and two
were females. He says the whole region over which the
disease extended, viz., Sutton, and the neighborhood, has a
soil very retentive of moisture, and a damp atmosphere.
The patients, with the exception of one fifty years of age,
averaged ten years. The earliest age was five years. The
section in which the disease prevailed, may be roughly esti-
mated to be eight miles long and five wide. Scattered cases

CEREBROSPINAL MENINGITIS. 55

of extreme severity occurred at about the same time in nearly
all parts of that section. In a few instances several mem-
bers of a family were attacked, but generally only one mem-
ber. Dr. T. found no evidences of contagion. The average
duration of the cases was fourteen days, the longest forty
days, the shortest ten hours. Convulsions occurred in two
cases of the six.

Headache was present and very severe in all the cases
but one ; in that one there was profound stupor from the
onset. There was delirium in nearly all the cases, but not
violent. The patients disliked to be moved or touched.
When aroused to answer a question, the answer was usually
short and petulant, sometimes logical, sometimes not. The
head was drawn backwards in nearly all the cases. In one
case the body was curved backwards nearly to a semi-circle.
Petechia? occurred before death in two at least of the six
cases, and remained after death. Dr. Terry thinks they
covered the bodies after death in most cases, but cannot
positively so state.

Dr. Terry had but one post-mortem. That was in a case
of a boy five years old, who died in ten hours after the
attack. Dr. T. finds a memorandum, which says, " the large
veins and sinuses of the brain were found much engorged
with blood, the membranes (cerebral and spinal) injected,
the spinal cord softened. Much turbid serum had been
effused." Only the upper part of the spine was examined.

The treatment was by emetics and cathartics in the com-
mencement, followed by diaphoretics, blistering the nucha,
sinapisms to the legs and other parts. Warm baths in some
instances. Only one of the cases was freely bled, and that
was the only one that recovered.

Dr. H. E. McCollum claims to have had a few cases of
the disease in Barnstable, in November, 1847. There were
petechia?, but no opisthotonos.

56 REPORT.

THE PRESENT EPIDEMIC,*

AS RELATES TO MASSACHUSETTS.

The question of the present epidemic in this State is now
before us.

We will begin this part of our report with two cases,
which we give from the records of the Boston Society for
Medical Improvement, as specimens.

Case XI. April 11th, 1864. Cerebro-S^inal Meningitis.
Dr. Ellis reported the following case.

On April 4th, a young man came home from a store, in
which he was employed, with a slight headache, but as he
had been subject to this for several years, it attracted no
particular attention. In the evening, however, it increased,
and was followed by vomiting during the night. He con-
tinued about the same through the following day, and sat up
long enough to have his bed made; but that evening he
made strange answers, and sat up in bed. A homoeopathist
was called, but before his arrival the patient was attacked
with spasms, which continued till towards morning, when
the patient died suddenly, thirty-six hours after the com-
mencement of the disease. The symptoms were attributed
to poisoning, and no medicine was given.

At the examination made on April 6th, at 4, P.M., the
arachnoid was found dry, and the convolutions somewhat
flattened. There was no perceptible change in the cerebral
substance, nor effusion into the lateral ventricle. The pia

* Our account is necessarily made up no later than January, 1866, most of the
cases reported to us having been sent in before that time.

CEREBRO-SPINAL MENINGITIS. 57

mater of the -brain and spinal cord was opaque and infiltra-
ted with thin pus. No apparent change in the tissue of the
spinal cord. The bladder contained a large amount of
urine. The spleen was somewhat enlarged.

Dr. Ellis remarks that " although the amount of pus was
not so great as in some cases, the appearances were une-
quivocal." The short duration of the case may perhaps
explain the limited development of the disease.

Case XII. April 11th, 1864. Dr. Coale reported the
following case.

E. B., aged fourteen weeks, a healthy infant, about Janu-
ary 27th, was observed to be restless and fretful, and to
throw herself backwards frequently. Gradually her habitual
position became one of flexion of the spine backwards, par-
ticularly in the region of the neck. She was brought to
Boston and put under Dr. C.'s care, February 10th, just two
weeks after the first signs of the attack. He found her
lying on the side, the head bent backwards. The spine was
also curved. The pulse was 100, regular. The bowels
somewhat costive. There was no twitching of the limbs, no
distortion of the face or squinting. The pupils were con-
tracted. This state of things continued without alteration,
except an increase in the intensity of the symptoms. Death
took place February 19th, twenty-three days from the first
appearance of the disease. At the time of death there was
thorough opisthotonos, the trunk being bent backwards in
the form of a semi-circle. There was no discoloration nor
any spots on the skin. The treatment consisted in altera-
tives and revulsives to the spine, but without effect.

Though there was no autopsy in the last case, we consider
it sufficiently characteristic to be of interest.

58 EEPOET.

The Committee now offer the results of certain special
investigations made by them, as to the history of the present
epidemic in this State.

SPOTTED FEVER, OR CEREBRO-SPINAL MENINGITIS
IN PUBLIC CIVIL ESTABLISHMENTS OF THE
STATE.

We have made inquiries as to the occurrence of the dis-
ease in certain of the public civil establishments of the State,
taking the entire list of " State Charities," so called, with the
exception of the Hartford Asylum for deaf mutes, which is not
in the Commonwealth ; and also of the Eye and Ear Infirm-
ary, which is omitted for obvious reasons. This list is as
follows, viz. :

The Blind Asylum at South Boston ; the Idiotic School at
South Boston; the Westborough School; the Lancaster
School ; the Tewksbury Almshouse ; the Monson Almshouse ;
the Bridgewater Almshouse ; the McLean Asylum at Somer-
ville; the Taunton Hospital for the Insane; the North-
ampton Insane Asylum; the Worcester Insane Hospital;
the Lunatic Hospital at South Boston ; the School Ship in
Boston Harbor ; the Hospital at Rainsford Island, Boston
Harbor; the Deer Island Hospital, Boston Harbor; the
Washingtonian Home, Boston; the County Receptacle at
Ipswich ; the House of Correction at South Boston ; the State
Prison at Charlestown ; the Massachusetts General Hospital,
Boston.

Together with this list should be taken into account the
Boston City Hospital ; and the Dale General Hospital, at
Worcester, which latter, though an asylum for soldiers, is
hygienic ally not of a military character.

In the Massachusetts General Hospital there have been

CEREBROSPINAL MENINGITIS. 59

two cases. The patients having been carried there with the
disease upon them, they are to be credited to the city of
Boston, and do not count here.

In the Boston City Hospital there were, during the winter
of 1864 to '65, Jive cases, which originated in the Hospital.

In the Monson Almshouse there have been two cases. In
none of the other above-mentioned institutions have there
been any cases.

THE DISEASE IN THE LATE MILITARY ESTABLISH-
MENTS WITHIN THE STATE.

We have also obtained, through the kindness of Assistant
Surgeon General Hooker, the following list of the Military
Camps and Rendezvous of Massachusetts, viz. : Camp Wool,
Brook Farm, and Camp at Fair Grounds, Worcester ; Camp
Cameron, North Cambridge ; Camps Stanton and Schouler,
Lynnfield; Camps Massasoit, Brigham, and Meigs, Read-
ville ; Camps Wilson, etc., at Lowell ; Camp Stanton, at
Boxford ; Camp Joe Hooker, Lakeville ; Camp Stevens, Gro-
ton Junction ; Camps Reed and Banks, Springfield ; Camp
Miller, Greenfield.

In none of these camps, all of which were remarkably
free from sickness of every kind, was there any of the " spot-
ted fever," or " cerebro-spinal meningitis."

But, in the same category belong the military establish-
ments in Boston Harbor. Of these, Gallop's Island, Fort
Warren, and Fort Independence, only have held any consi-
derable bodies of men ; and the two first — Gallop's Island
and Fort Warren— alone have been visited by the dis-

60 REPORT.

ease. At Gallop's Island there have been 19 cases, and at
Fort Warren 4 cases. The four cases at Fort Warren were
recruits who went from Gallop's Island during the preva-
lence of the disease at the latter place, and are considered,
by the medical officer reporting them, as to be credited to
Gallop's Island.

At other places there have been only small garrisons or
guards. Among these there has been none of the disease,
as we are assured by a letter from Dr. Mc Laren, the Medical
Director, which tells us that, with the above exceptions, it
has not occurred in any of the forts, camps or rendezvous
in his district.

SPOTTED FEVER OR CEREBRO-SPINAL MENINGITIS
NOT PROVED TO BE A "MILITARY DISEASE'7 BY
THE LATE EXPERIENCE OF MASSACHUSETTS.

We find ourselves unable to set up a numerical compari-
son of the civil with the military establishments in the State,
as to the relative amount of the disease among them, because
while the former are permanent, the latter have existed for
limited periods ; because the numbers of troops at different
points have of course fluctuated a good deal : and because
of other varying circumstances in the history of the camps.

We are reduced to saying that the disease has occurred
to a slight extent in a small proportion of the civil institu-
tions above mentioned, i. e., in 2 out of 22 ; and also in a
small proportion (2) of the whole number of military estab-
lishments in the State, however reckoned — considerably in
one, to a slight extent in the other.

CEREBROSPINAL MENINGITIS. 61

We may, however, remark that there have been one or
more military camps, at different points, or successively at
the same point, in ten towns in the State ; and, also, consi-
derable bodies of troops on three of the Islands in Boston
Harbor, besides the inconsiderable garrisons or guards
already mentioned. Where two or more camps are set
down as in the same town, they have occupied the same spot
either successively or together, except in Worcester, in which
place the camp at Brooks Farm and that at the Fair
Grounds were on widely separated sites.

Worcester, then, should be considered as furnishing two
distinct military centres ; the other 9 towns, one each. We
may say, therefore, taking the eleven camps on the main-land,
together with the three islands above mentioned, that the
disease has occurred in 2 out of 14 principal military cen-
tres, so to speak, within the limits of the State.

Though the records of " spotted fever," or " cerebro-spinal
meningitis," in this State, consist largely of cases from private
practice, most of which we have not yet presented, we will here
give our impression that while the experience of Massachu-
setts does not furnish grounds for any definite conclusions
as to whether the disorder does, or does not, specially affect
military camps or barracks, yet on the other hand it does
not authorize us to consider it, as it is regarded by some
in France, a military disease.

Over-crowding alleged to be a cause op the Disease.

Dr. Page makes an interesting statement as to the be-
havior of the disease at Gallop's Island. He says the
September case occurred at a period of great over-crowding.
This over-crowding was abated, and nothing more was seen
of the disease till January 29th, when the barracks were
again over-crowded, there being from 130 to 180 men in a
barrack intended for 100. Dr. Page presaged the renewal

62 REPORT.

of trouble, and reported the danger to the Government
begging that the over-crowding might be relieved, but in vain.

The cases went on appearing one after another, till the
surplus number of men were shipped off, when it ceased.
Dr. Page expresses a decided opinion that the disease at
Gallop's Island arose from over-crowding.

Now, the question may be asked, whether the occurrence
of the disease in military establishments be not owing, gene-
rally or frequently, to crowding too many men together in
tents and barracks, rather than to any thing special in mili-
tary life. If such should be found to be the case by any
having a large number of military statistics within reach, such
crowding can only be admitted to be one of the causes of the
malady, since, as we have seen, it has preferred the country
town, or village, to the large city, and has often visited the
solitary farm-house. At the City Hospital, too, the patients
were the reverse of crowded, and their wards were remark-
ably well ventilated.

Number op Cases in the Towxs where there were
Military Camps.

We subjoin, as perhaps not uninteresting, a statement of
the number of cases reported in the towns in which were
situated the military camps.

In Worcester, with 24,960 inhabitants (by last census),

there were 6 cases ; in North Cambridge, inhabitants,

no cases; in Lynnfield, with 866 inhabitants, 1 case,' in
Dedham (including Readville), with 6,330 inhabitants, no
cases; in Lowell, with 36,827 inhabitants, no cases; in Box-
ford, with 1,020 inhabitants, 1 case; in Lakeville, with 1,160
inhabitants, no case; in Groton,* with 3,193 inhabitants, no
cases; in Springfield, with 15,199 inhabitants, 11 cases; in
Greenfield, with 3,198 inhabitants, 3 cases:

* In Dedham, Lowell, and Groton, the negative evidence is very decided.

CEREBROSPINAL MENINGITIS. 63

At the U. S. military posts in Boston Harbor, where the
disease appeared, the military were the only inhabitants.

It appears from this statement that the epidemic had
rested somewhat upon some of the towns where were the
military establishments, while in others of those places it
had not shown itself. Yet, in none of such establishments,
except those in Boston Harbor, with no civil surroundings,
did the disease occur.

An examination of the tables shortly to be given, will
show that in none of the places where the disease struck its
strongest blows, were there military camps, rendezvous, or
barracks.

Proportion of Recruits affected.

Are recruits more liable, as has been stated in France, to
"spotted fever," or " cerebro-spinal meningitis," than vete-
rans ? The affirmative is not sustained by the experience
of Gallop's Island. At that place there were 19 cases re-
ported, besides very slight ones not recorded: 13 of these
19 were recruits,- 4 old soldiers; 2 not described. But,
of the old soldiers on the Island, Dr. Page writes us, twenty-
five hundred were recruits, and four hundred of permanent
garrison. Therefore, while the recruits on the Island were
to the permanent troops as about 6 to 1, the number of re-
cruits who had the disease to that of the veterans sick with
it, was only between 3 and 4 to 1 ; and that, even if we
count as recruits the " two not described."

64 REPORT.

THE CASES OF THE PRESENT EPIDEMIC IN MASSA-
CHUSETTS (AS COLLECTED UP TO JANUARY,
1866), ARRANGED IN TABULAR FORM.

We have consulted the State Registration reports in the
hope of finding in the registry of deaths, a statement of the
numbers of persons who have died of " spotted fever/' or
"cerebro- spinal meningitis." But neither of these nosolo-
gical terms appear among the " causes " of death. We have
fared no better with the report of the Registrar of the City
of Boston.

The information we have to present as to the experience
of private practice has, with the exception of what we have
derived from a few published cases, been obtained by cor-
respondence with the Fellows of this Society. Circulars
were printed, with the following heading, viz. :

"Boston, August 1, 1865.

"Dear Sir : — The Committee of the Massachusetts Medical
Society on ' Spotted Fever,' respectfully ask you to fill out
this blank with reference to any cases of ' Spotted Fever' —
otherwise termed ' Cerebro-spinal Meningitis ' — which may
have occurred in your practice. If you have not had any
cases, the Committee nevertheless earnestly ask you to write
1 No ' to the first question, and forward as directed.

" Please transmit to the undersigned, at No. 6 Chestnut
Street, Boston, Mass. For the Committee,

" Luther Parks, Jr., M.D., Chairman."

The Circulars were mailed to each Fellow of the Massa-
chusetts Medical Society. To address them we procured

CEREBROSPINAL MENINGITIS. 65

the services of the book-keeper of the Boston Medical and
Surgical Journal, who had the most perfect list extant of the
members of the Society. He informs us that he sent out
over nine hundred. It is to be regretted that the importance
of returning negative replies was not universally appreciated,
as we are left without reports from a large proportion of
the towns in the State ; though the thanks of the Society are
due to the associate members of the Committee for their
efforts to get the circulars returned.

The Chairman wrote to the other members of the Com-
mittee asking them to canvass their respective districts. He
feels assured that they used every exertion to get the circu-
lars sent in ; and, from the tone of their correspondence, is
led to the belief that no considerable number of recognized
cases remain unreported.

The queries propounded in the circulars need not be
stated here, as they can be inferred from the headings of the
tables below. Other important questions we should have
been glad to put, but acting by advice, we aimed at making
the list of queries as short as possible, and felt that, as it
was, it had extended to as great a length as the indulgence
of our correspondents would bear.

The total number of cases directly reported, and which
will be reckoned upon, in calculating the ratios of ages,
symptoms, &c, is 287. But in apportioning these cases
among their respective counties, two of them must be ex-
cluded, as having occurred in Whitingham, Vermont. These,
however, are grouped together with others of Dr. Temple, in
Heath and Rowe, Berkshire County, and cannot be isolated
in taking account of the symptoms and other circumstances.
Whitingham adjoins Heath and Rowe.

Likewise in the above-mentioned apportionment of cases
among the Counties, there are 23 cases which occurred in
Boston Harbor, which are to be left out ; as also should 7

66 EEPOET.

cases in Brookline, Norfolk County, occurring in 1866, while
the reports for the other towns were closed before the
present year.

For this reason, again, in reckoning the number of towns
(relatively to their respective Counties), which sent affirma-
tive replies, Brookline must be excluded. In the remaining
calculations all the 287 cases will be counted in.

With this preface we give the tables we have prepared to
embody the replies which have been received.

Tables compeising 287 Cases.

When there is not room in the tables for "Autopsies,
Treatment, Remarks," these are appended, the cases to which
they refer being indicated by Roman numbers corresponding
with similar numbers in the tables.

Reading the tables horizontally we get a sketch of each
case, or set of cases, so far as furnished by their reporters.;
reading vertically we obtain the aggregate results as bearing
upon the several points investigated in the tables.

IT- ]

NAMES OF TOWNS.

Names of Reporters.

o
6

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts

thickly or

sparsely settl'd

Condition
of Patients.

to
<!

<
<

Of Adults.

Adv. Mid.
Age. Age.

o
<1

First case in

Town, so far

as known by

Reporter.

Last case in |
Town, so far i
as known by j
Reporter.

« t, «
05 W

g 3,2

"5 2 5

a C

4J C

5 £
5JP

5.2

Convulsions.

No. of eases in

which they

occurred.

Boston,
Suffolk Co.

A. A. Gould, M.D.

Apr. 6, 1864.

Low and damp, just

above and near

tide water —

U. S. Hotel.

Medium.

Easy
circumstances.

26 yrs

26 "yrs

26 yrs

Sporadic.

4ds.

about
4 w.

4ds.

Boston,
Suffolk Co.

S. Cabot, M.D.

April, 1864.

Low. 1 Albany St.,
near TJ. S. Hotel.
1 in Williams St.

Not crowded.

Easy.

2 yrs

about
4 w.

Boston,
Suffolk Ct>.

G. Hayward, M.D.

Mar. 26, 1S64.

Easy.

6 yrs.

6 yrs

30 h.

1 also jactitation.

Boston,
Suffolk Co.

Calvin Ellis, M.D.

Apr. 4, 1864.

Easy.

17 yrs.

36 h.

1 Boston,

Suffolk Co.

W. E. Coale, M.D.

Jan. 27, 1864.

Easy.

14 w.

23 ds.

23 ds

Boston,
Suffolk Co.

Calvin G. Page, M.D.

Sept. 26, 1865.

Preceded by Symp-
toms of cold, attribu-
table to exposure.

Easy.

14 ds

14 ds.

South Boston,
Suffolk Co.

J. F. Gould, M.D.

June 30, 1864.
July 3, "
July 17, "

Not known.

High.
Soil hard and dry.

All in one
louse. District

not very
rnickly settled.

Poor.

22 yrs.

42 yrs.

7 yrs.

Sporadic

9ds.

4ds.

3 w.

Boston,
Suffolk Co.

[Sent to Mass. Gen. Hos J

Under care of
J. B. S. Jackson, M.D.

Feb. 25, 1864.

Not recorded.

Easy.

26 yrs.

Not
recorded

31 ds.

31 ds

31 ds.

Boston,
Suffolk Co.
i Sent to Mass. Gen. Hos.]

Under care of
A. A. Gould, M.D.

Feb. 27, 1864.

Not recorded. .

Vine Street — low.

Thickly.

Easy.

17 yrs.

ditto.

23 ds.

Boston City Hospital,
Suffolk Co.

J. N. Borland, M.D.

Nov. 5, 1864,

to
Dec. 3, 1864.

Sparsely.

ditto.

2 fatal
n few

lis. ea.
1 ree.
4.} m.

1,5m.

1, 8w.

(a few
h."

about
5 m.

In all three of the
cases fully
described.

Gallop's Island Bar-
racks, Boston Harbor.

Calvin G. Page, M.D.
V. Surgeon XL S. Army.

1 Sept. 14, 1864.

18 Jan. 25, 1865, to

April 11, 1865.

Overcrowding in

barracks. Possible

contagion in 2.

High and dry.

' Over-
crowded.

Soldiers.

21 yrs.

6
i

40 yrs.

15 yrs.

Soldiers.

Sept. 14,
1864.

Apr. 11,
1865.

Epidemic.

2 ?

about
4J ds.
fatal.
56 ds.
recov.

Acute

jymp

min.

about
4 m.
recov.

0. But uneasiness

or jactitation in

a majority.

Fort Warren,
Boston Harbor. (

Joel Seaverns, M.D.
A. A. Surgeon TJ. S A.

Feb. 26,
Mar. 17,
Mar. 18,
Mar. 23,
1865.

The barracks on

Gallop's Island.

Patients all recruits

from thence.

Low point running

into the sea, but not

wet by the tide.

Over-crowded
while at Gal-
lop's Island.
At Fort War-
ren, as usual
in military
quarters.

Soldiers.

31 yrs.

15 yrs.

7 yrs.

Soldiers.

Fob. 26,
1865.

Mar. 23,
1865.

Epidemic.

4 11 ds.

12 h.

37 ds

No general convul-
sions, but much
convulsive action
in all.

Heai
No. of
which i

1 inte
conti

Not kno

tients t

to manifi

was si

■2 se
1 sli

1 seve
cons

Pain se

front par

extendin

and In

shou

Of the 3 i
ly des<
2 sevi
lslig

In all tl
develop!

In all.
excruc

Headache.
No. of cases in
which it occurred

Delirium.
Character of.

Opisthotonos
severe.

Opisthotonos
slight.

Tenderness
at Nucha.

Pulmonary and
Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

Terminat'n.

Autopsies.

Treatment.

Remarks.

1 intense and
continuous.

Became unconscious on

2d day, and never

spoke after.

No proper opisthotonos,

but torsion and rigidity

of neck.

Not ascer-
tainable.

Bronchial cough a

day or two previous

to visit.

Nothing peculiar
remembered.

Small, purplish, permanent
petechia; everywhere. Swell-
ing and redness of knuckles.

XXXVII.

Not known. Pa-
tients too young
to manifest. There
was shrieking.

Too young to manifest.

Pulse
not particularly quick.

Hydviod. potassa.

There was convalescence,
followed by relapse in both.

Loss of consciousness.

Respiration hurried
and labored. Con-
gestion.

Pulse 120 — varied in
force.

Nausea.

Small, round, purplish dots, in-
creasing in size& numbers, clear

and distinct, not raised. On
right arm an irreg. shaped blotch

Iik,e purpura, 1 in. by 1 1-3.

Others on body and limbs.

1 emetic — stimulants, hot

applications, sinapisms,

nourishment.

Vomiting.

Reported
above, p. 56.

Nil. Not under care
of Dr. Ellis.

Not known.

1 severe;
patient bent
to semi-
circle.

Pulse 1Q0 — regular.

Slight cos-
tiveness.

Alteratives, revulsives
to spine.

Slight delirium.

Coarse rales at base

of chest; difficult

expectoration.

Pulse variable.

Bowels cos-
tive, urine
scanty.

Petechia? abundant on forehead,
chest and back.

Stimulants, quinine, ky-

driod. pottassa,

counter-irritation.

Paralysis of limbs, particularly

on the right side ; could not

feed himself nor turn in bed.

Some paralysis of muscles of

speech and deglutition.

2 severe.
1 slight.

2 cases. Logical answers
in 1.

2 severe.
1 slight.

3, pulse accelerated.

Petechia; in 2. In 1 on neck

and chest, size of quarter dollar.

In the other like flea bites on

body — transient in both.

XXXVIII.

1 severe and
constant.

Active at first, then mere

wandering, from which

he could be roused.

■?

Slight cough, with
pain at base of the'

right lung.
No physical signs.

Pulse 100 to 120— full
and regular.

Tenderness,

costiveness,

Ischuria

vesicalis.

None recorded.

XXXIX.

Pain severe in

front, part of head,

extending to neck

and between

shoulders.

1. Logical answers.

*Tot recorded

Respiration labored.

Pulse varied in force,
and from 88 to 120.

Vomiting.

Slight

tenderness,

retention of

urine.

Skin hot and dry; no spots
recorded.

XL.

Leeching, cathartics,
mercury, opiates, and
diffusible stimulants.

Attack came on with chills and
. vomiting. There was deaf-
ness and multiplied vision.

Of the 3 cases ful-
ly described,
2 severe,
1 slight.

Of 3 cases fully describ-
ed, 2 were delirious and
and both of them gave
logical answers.

Of 3 cases
tally deserib.
1 had severe
jpisthotonos.

Of 3 cases
ully deserib.
1 had tender-
ness of, and

1 pain at
nucha.

Of 3 cases fully de-
scribed, 2 had labor-
ed or hurried
respiration.

Of 3 cases fully described,

in 1 the pulse was 96,

in 2 it varied.

Of 3 cases
fully desert).
constipation

in all 3,

vomiting in

XLI.

In all the fully
developed cases.

n all the fully developed

cases but one ; in that

one, coma. Logical

answers generally.

Save in one
case, not se-
vere. In 1,
-.mprosthoto-
nos. See
'•Remarks."

In about
two thirds
of the cases.

Probably in
all.

Respiration abnor-
mal in about half the
cases.

Pulse generally
abnormal.

Nausea or
vomiting
frequently
an early
symptom.

Petechia; very general, though
variable in size and sometimes
slight. In 1 surface nearly black.
In another they sloughed, and
were followed by formation of
crusts in thin layers, desquamat-
ing fnrfuraeeously from the top.

0
Not allowed.

Tonic, and freelv stimu-
lant. "

XLII.

In all. In some
excruciating.

In all. Logical answers
n all cases at some times ;
at other times there was
very violent delirium, or
occasionally of a low
muttering character.

In all 4.

None, except in 1
case. Decided hepa-
tization in one lung
in that.

Pulse small, frequent,
100 to 140.

Meteorism
in all 4;
Diari'licea
with invol-
untary dis-
charges in 1.

Petechias in all 4; in size from
a point to qr. in. in diam., of a
red, violet or black color, not

perceptibly raised — coming on at
first invasion and fading out in

few days if patient lived so long.

Occasion'ly returned in less deg.

0
Not allowed.

Quinine and brandy

freely, opium and

valerian.

XLIII.

E ]

NAMES OF TOWNS.

Names of Reporters.

o
o
d

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts

thickly or

sparsely settl'd

Condition
of Patients.

- <;

1
>
<

"3
<

Op Adults.

Adv. Mid.
Age. Age.

o
<

■SIS'

2 c
O

to
<

First case in

Town, so far

as known by

Reporter.

Last case in

Town, so far

as known by

Reporter.

■a g

° p.
02 W

■SSI

«■■: a

°.S O

ffl B

fcc.2
> a

u B

§.2
la g

y ~
Oft

Convulsions.

No. of cases m

which they

occurred.

Boston,
Suffolk Co.

C. E. Ware, M.D.

1864-65.

Not known, except
that oue came from
the school at Pitts-
field, where so many
cases occurred.

None were in the

highest parts of the

city.

Not crowded.

Easy
circumstances.

about
half
the

cases.

about
half
the

cases.

60 yrs.

11 yrs.

Fatal
13 d.
Recov
say
4 w.

10 ds.

5 w.

Boston,
Suffolk Co.

C. E. Buckingham, M.D.

Mar. 29, 1864.
Apr. 23, "
May 6, "
Sept. 29, 1865.

In one supposed

from malarial

exposure — an officer

in the artillery.

Tremont, Worcester,

Parker and Pleasant

Streets — all on a

low level.

Not crowded.

Easy.

21 yrs.

35 yrs.

5 yrs.

Mch. 29,
1864.

Sept. 29,
1865.

Sporadic.

ui S

1 fatal
less
than
24 h.

1 reco.
many
mos.

]

In one only,
a child.

Boston,
Suffolk Co.

H. J. Bigelow, M.D.

May 2, 1865.

Not known.

High and dry.

Not crowded.

Easy.

23 yrs.

5ds.

■ 1

Boston,

Suffolk Co.
Roxbuiy,
; Norfolk Co.

L.B.Sheldon, M.D.

2
2

1 Apr. 7, 1865.

1 July 20, "

2 Aug. 1, "

Over-fatigue and
want of cleanliness
and nourishment.

Low and damp.

Thickly.

Poor.

12 yrs.

17 ms.

Aug. '65

Sporadic.

2ds.

Boston,
Suffolk Co.

A. D. Sinclair, M.D.

Apr. 30, 1864.
May 1, "
Jan. 24, 1865.

Not known.

No preference.

Thickly.

Easy.

19 yrs.

46 yrs.

4 yrs.

Apr. '64.

Jan. '65.

Sporadic.

24 ds.

10 ds.

7w.

In two cases ;
1 severe, 1 slight.

Boston,
Suffolk Co.

Th. H. Hoskhis, M.D.

Oct. 2, 1862.

Not known.

Northneld Street ;
low, not damp.

Not crowded.

Easy.

23 yrs.

4 ds.

4ds.

Boston,
Suffolk Co.

W. 0. Johnson, M.D.

April, 1864.

Not known.

Made land, near
Charles River.

Thickly.

Poor.

40 yrs.

Apr. '64.

Sporadic.

4 w.

Boston,
Suffolk Co.

J. S. Jones, M.D,

1865.

No record.

Boston,
Suffolk Co.

Anonymous.

Feb. 20, 1864.

Severe cold weather.

High and dry.

Crowded
neighborhood.

Poor.

9 yrs.

Sporadic.

43 h.

Boston,
Suffolk Co.

Anonymous.

Dec. 1864.

Not known.

Dry.

Easy.

3 yrs.

Dec. '64.

Sporadic.

4ds.

Boston,
Suffolk Co.

B. S. Shaw, M.D.

July or Aug. 1863.

Traumatic.

High and dryi

Not crowded.

8 yrs.

10 ds.

10 ds

Joston,
Suffolk Co.

William Read, M.D.

May 18, 1864.

Easy.

26 yrs.

about
2Jm

about
2J m.

about
24 m

No clonic spasms,

hands clenched,

arms strongly

flexed, feet inverted

E ]

to.2
> a

oqO

£ 5
OR

Convulsions.

No. of cases in

which they

occurred.

Headache.
No. of cases in
which it occurred.

Delirium.
Character of.

Opisthotonos
severe.

Opisthotonos
slight.

Tenderness
at Nucha.

Pulmonary and
Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

Tekminat'n.

■p
">
° "3

Autopsies.

Treatment.

Kemarks.

Fatal
13 d.

Secov
say

4 w.

10 ds

5w.

Present, but not a

marked feature

in any case.

" Violent in some, active

in all ; only coma in

fatal cases."

Not marked.

Pulse generally frequent,

but nothing peculiar

about it.

Not promi-
nent, though
a little diar-
rhoea in some
of the cases.

Petechia? distinct in 5 cases.
One of the other cases was in

the same family with two of
these cases, and was evidently
the same disease, but no erup-
tion could be discovered.

XXXIV.

3 cases fatal in 10, 12 and 19
days; 4 recovered in from 3 to
6 weeks .
XXXIV.

oo a

1 fatal
less
than
24 h.

1 reco.
many
mos.

In one only,
a child.

In 3 cases. In the
child stupor alter-
nated with con-
vulsions, and
headache could
not show itself.

In 2 fatal, adult. Logi-
cal answers in one until
within 12 hours before
death. In the other
no logical answers
for 48 hours before
death.

Not recorded

In 2. In one
other exces-
sive pain.

In all 4 respiration
hurried. Pain in I.

Pulse accelerated in all 4.

Nausea and
vomiting a
frequent
symptom.
Diarrhoea in
1 fatal case.

Petechia; in 3 ; absent in one of

the three fatal cases. They
appeared on various parts of
the body and extremities. They

consisted of small spots as of
effused blood, from diameter of
crow-quill to that of a lead pen-
cil, distinct, some round, some
irregular, and in no case dis-
appearing on pressure. In the
case of recovery they became
(from purple) gradually a light
pink, and gradually passed
away.

Opiates, iron, stimulants,
broth.

1 case was fatal in 2 J days ; one
was fatal in less than 24 hours ;
one in about one week. In the
case of recovery it was months.

In one case there was
obtuse hearing, loss of muscu-
lar power. In the case of re-
covery, rheumatic disease super-
vened and obscured paralysis of
motion, which existed for
months.

5ds.

• 1

Present 1 case. Logical

answers to a certain

extent.

Spots in moderate number,

chiefly on the lower limbs.

1 case.

Excessive prostration and sink-
ing from the first.

2ds.

Quick and strong.

Spots in all 4. In one case

a spot on the hand, another on a

foot, a third on abdomen

sloughed.

XXXV.

4ds.

10 ds.

7w.

In two cases ;
1 severe, 1 slight.

In 3. Constant

back of head

especially.

Mild in 3. Logical
answers.

In two cases great
distress in chest.

Pulse 140 to 150.

Great pain
in 2 cases.

Quinine, aconite, hydriod.
potassas.

4 ds.

4ds.

1 severe.

High first day, low mut-
tering second day.
Logical answers.

^ot recorded

Pulse rapid and bound-
ing at first — strong
almost to the last.

1 case. Petechia; large and
numerous.

Case past treatment when
seen.

Dr. Hoskins had another case,

seen by another practitioner,

among whose cases it has been

given already.

4w.

4 w.

1 delirious and persist-
ently inattentive ;
finally comatose.

Pulse slow.

1 case. Purple ecchymoses
on tibia.

Calomel, purging, opiates,
sinapism to nucha.

Tongue white and moist.

No record of the cases had
been kept.

13 h.

43 h.

1 intense.

Not noticed.

Pulse 180, very weak.

Vomiting.

Skin " pungently " hot ; gene-
ral mottled look on face and
arms. Spots exactly like pur-
pura on limbs and trunk.

Stimulants, spts. ammon.
aromat.

XXXVI.

4ds.

1 severe. Pain

extended down to

third or fourth

dorsal vertebra.

Slight in one case.
Logical answers.

Pulse moderately
accelerated.

Cathartics, counter-irri-
tants, stimulants,
anodynes.

Premonitory symptoms for
three days.

10 ds.

1 mild. .

Some delirium constantly.
Logical answers.

Pulse 130, weak.

Stimulants, counter-irri-
tation to neck, cold to
head.

The boy fell from a tree and
struck his head and spine.
Suggestion on treatment: " Ex-
periment and study."

about
2 J m.

about
2Jm.

No clonic spasms,

hands clenched,

arms strongly

flexed, feet inverted

Delirium and stupidity.
Logical answers in inter-
vals of comparative
intelligence.

No, but pain
between
shoulders.

Severe pain through
upper part of chest,
affecting respiration.

Pulse variable and
irregular.

Vomiting ;
urine invol-
untary ; then
catheterism
required.

At different dates, purpuric
spots on the eyelids, upper
part of body and arms. At one
time legs and feet purple. Body
and legs became dotted with a
pustular eruption. Hard in-
flamed spots like boils, with sup-
purating apices, interspersed
with pustules exactly resembrg
variola, but which did not dry
up into a crust, but became fill'd

with blood and remained so.

Finally whole body became cov.

with boils' and abscesses, one of

which was opened and gave

laudable pus.

Diffusible and alcoholic
stimulants, antispasmo-
dics, opiates, iron, two
leeches to temples. No
apparent benefit except
from stimulants and
opiates.

At one time the tongue was

protruded a little to the right

side. There was deafness,

also jactitation.

: *>

NAMES OF TOWNS.

Names of Reporters.

8
o

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts

thickly or

sparsely settl'd

Condition
of Patients.

>
<

bfl

Of Adults.

Adv. Mid.
Age. Age.

■a
<

s @
§1

o
bo

First case in

Town, so far

as known by

Reporter.

.Last case in

Town, so far

as known by

Reporter.

'•& S
p. °<

■SSI

.So

c 0
b0.2

> a

w_0

° h
■9.5

8.8
1 S

Convulsions.

No. of cases in

which they

occurred.

Billerica.
Middlesex Co.

F. Bundy, M.D.

Feb. 26, 1864.
Jan. 21, .

Both cases followed
a sudden cold.

2 low, 1 clamp, near
a small river.

1 village.
1 house stand-
ing alone.

Easy
circumstances.

29 yrs.

36 yrs.

22 yrs

Feb. 26,
1864.

Jan. 21,
1866.

Sporadic.

about
5ds.

52 h.

8ds.

S. Beading

Middlesex Co.
Lynntield,

Essex Co.

C. Jordan, M.D.

2
1

Dec. 4, 1864.
Feb. 22, 1865.

Not known.

No preference.

Thickly settled

2 easy,
1 poor.

13yrs.

21 yrs.

7 yrs.

.R.

Dec. 4,

1864; L.

Feb. 22,

1865.

Sporadic.

10 ds.
8h.

36 h.

4 w.

Amesbury,
Essex Co.

Thomas Sparhawk, M.D.

July 16, 1865.

Not thickly.

Easy.

2iyrs.

2Jyrs.

2£yrs.

Sporadic.

24 h.

Sometimes

confined to one

side, or a limb.

Boxford,

Essex Co.
Topsfleld,

Essex Co.

Justin Allen, M.D.

March and Nov.
1864.

Nothing definite.

No preference.

Sparsely.

Poor.

5J yrs.

8 yrs.

3 yrs.

Mch. '64

Mch.'64.

B.
Nov. '64

12 ds.

3ds.

21 ds.

Danvers,
Essex Co.

George Osborn, M.D.

Sept. 1864.

Not known.

High land.

Sparsely.

Easy.

26 yrs.

Sept. '64

Sporadic.

12 ds.

Clonic spasms,

knees drawn up

stifny.

Medfield,
Norfolk Co.

S. E. Stone, M.D.

May 5, 1865.

24 yrs.

May 5,
1865.

Sporadic.

4ds.

West Roxbury,
Norfolk Co.

George Faulkner, M.D.

March 9, 1864.

Not known.

20 yrs.

Mch. 9,
1864.

Sporadic.

12 m.

Roxbury,
Norfolk Co.

G. J. Arnold, M.D.

Not known.

No preference.

10 yrs.

Say
42 h.

Walpole,
Norfolk Co.

Eben Stone, M.D.

Dec. 13, 1864.

Sudden cold.

No preference.

41 yrs.

Dec. 13,
1864.

Dec. 13
1864.

3ds.

Continued clonic

spasms.

Brookline,
Norfolk Co.

S. Salisbury, M.D.

Jan. 4, 7, 14, 18,
20, 21, 29—1866.

Probably impure air.

Low and damp.

Thickly.

Easy.

8J yrs.

Child-
ren
ch'fly.

20 yrs.

3 yrs.

Jon. 4,
1866.

Jan. 29
1866.

Sporadic.

Fatal
48 h.
Recov
10 ds.

8h.

Not frequent.

Dorchester,
Norfolk Co.

J. S. Greene, M.D.

May 5, 1865.

Patient had played

around stagnant

water.

Dorchester.

4 yrs.

54 ds.

South Weymouth,
Norfolk Co.

F. F. Forsaith, M.D.

June 12, 1863.

Not known.

High land.

Sparsely.

Easy.

3 yrs.

Juno 12,
1863.

Juno 12
1863.

7w.

7 w.

New Bedford,
Bristol Co.

J. Henry Jennings, M.D.

1864-65.

Fan-haven,,
Bristol Co.

Geo. Atwood, M.D.

G
1

Feb. to May,
1865.

Not known.

No preference.

Thickly.

Easy .

10 yrs

Chief-
ly-

17 yrs.

5 yrs.

Dec. '64.

May, '65

Doubtful.

Say
7 ds.

3ds.

12 h.

Sav
28 (is

3ds.

Carver,
Plymouth Co.

Ben j. Fearing, Jr., M.D.

Feb. 1865.

Not known.

Dry.

Sparsely.

Easy.

Say
22 yrs.

Say
22 yrs

3 yrs

Sporadic.

3ds.

Barnstable,
Barnstable Co.

H. E. McColIum, M.D.

May, 1858.

Supposed contagion

or infection.

See " Remarks."

No preference.

Sparsely.

Easy.

4 yrs.

6 yrs.

May, '58

May, '5f

Sporadic.

2 ?

[ »

]

ap-ji

> a

£.2
g 3

Convulsions.

No. of cases in

which they

occurred.

Headache.
No. of cases in
which it occurred.

Delirium.
Character of.

Opisthotonos
severe.

Opisthotonos
slight.

Tenderness
at Nucha.

Pulmonary and
Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

Terminat'n.

Autopsies.

Treatment.

Remarks.

bout
j ds.

52 h.

8ds.

2 very severe.

Slight in one, decided in
the other i Mild in both.
Logical answers in both.

Not noticed.
But motion
caused se-
vere pain in
neck in both.

In one pulse very varia-
ble, in the other
unnoticed.

Petechia? in one, purple, from

the size of a pea to that of

a cent. Increased in size and

became darker. The skin

was not raised.

XXIX.

In both great tenderness of

surface on pressure. In one,

severe cramps in limbs and

abdomen.

)ds.
3h.

36 h.

4 w.

Severe.

Constant.
Logical answers.

• 0

2 cases.

Pulse in one, 50 per mln. ;
in two, 120.

In two cases small purple
spots over the body and limbs.

XXX.

4h.

24 h.

Sometimes

confined to one

side, or a limb.

Pulse 160.

No petechioe. Skin mottled
after death.

Evacuants, ether, then

whisky, quinine,

beef tea.

2ds.

3ds.

21 ds.

Peplaced by uncon-
sciousness.

XXXI.

2ds.

12 ds.

Clonic spasms,

knees drawn up

stiffly.

1 case. Logical answers
part of the time.

Livid, miliary petechia?,
sudamina.

Cordial, tonic, opiate.

ds.

4ds.

Severe.

1 case. Logical answers.
Delirium low, quiet.

Passive congestion

of whole of both

lungs.

Pulse very feeble, 83.

Petechia interspersed with

papules resembling urticaria

over whole surface. Extensive

ecchymoses on both legs

and on back.

Patient seen only in last
stage. Stimulants.

12 m.

Severe.

Not marked.

0 '

Not remembered.

Petechia? over the body on the
second day — some as large
as a silver three cent piece.

Supporting and
stimulating.

Patient died in one year after

months of activity but not

of recovery.

Say
2h.

Say
42 h.

Almost constant.
No logical answers.

Pulse not much disturbed

No petechia?.

ds.

3ds.

Continued clonic

spasms.

Delirium and coma.

Vomiting.

No spots.

Stimulants, opiates,
external irritants.

atal
8 b.
scov
)ds.

8h.

Not frequent.

Constant and ex-
treme in those
who could describe.

Delirium and logical
answers in all.

In all who

could
describe.

Pulse 120 to 130,
then 100.

Constipation
in all.

Not observed.

XXXII.

Ids.

>4 ds.

54 ds.

1 case. Logical answers.

Pulse 100 to 140*

Vomiting.

Bright red spots on neck, chest

and abdomen — some as if made

by blow from nutmeg grater.

•1

XXXIII.

7w.

1 severe.

Constant and profound.

Tonics and stimulants.

" Slow recovery after wavering

between life and death for

three weeks. Head nearly

touched the back between

the scapula?."

Eruption like purpura in both
cases.

Say
ds.

12 b.

Sav
28 ds.

3ds.

Say 5.

5 cases. Logical answers.

<2 •

Rheumatic carditis, 2.

Two cases nearly covered with

dusky rash in irregular patches

occasionally receding,

like roseola.

4
1

Tonics, stimulants,

nourishment, blister to

nucha.

ids.

3ds.

Nausea.
*

Cathartic, and blister
to nucha.

Eight pupil contracted, left

one dilated. Death in

eight hours from onset of

acute symptoms.

Petechia? about as large as rai-
sins, from 2 to 6 inches apart.
Resembled bruises ;
persisted post-mortem.

Opiates and cataplasms.

It was infection from fomites
that was inferred in this case.

[ o

]

NAMES OF TOWNS.

Names of Reporters.

9
u

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts

thickly or

sparsely settl'd

Condition
of Patients.

<v
60
of

a!
60

Of Adults.

Adv. Mid.
Age. Age.

T3
<

s
■§r?

o a
||

So
■<

60
<

"3
8

■a

First case in

Town, so far

as known by

Reporter.

Last case in

Town, so far

as known by

Reporter.

H3 S
a, fif

■8 81?

°.S o

60.2

2 "3

Hi!

"3 03

Convulsions.

No. of cases In

which they

occurred.

East Brookfleld,
Worcester Co.

Leicester,
Worcester Co.

E. M. Wheeler, M.D.

April, 1864.
July, 1865.

No preference.

Rather thickly

settled for
country town.

Easy
circumstances.

27yrs.

37 yrs.

17 yrs.

April,
1864.

July '65.

Sporadic.

4 w.

2w.

6 w.

Brookfleld,
Worcester Co.

J. T. Rood, M.D.

March 16, 1865.

Not known.

No preference.

Thickly settled

for country

town.

Poor.

6yrs.

6 yrs.

Feb. 4,
1865.

Mar. 16,
1865.

Sporadic.

8h.
to

con-
vales.

8h.
to

con-
vales.

8h.
to

con-
vales.

8 times an hour
on an average.

Barre,
Worcester Co.

C. W. Whitcomb, M.D.

April 6, 1864.

Not known.

Side hill near Ware
River.

Sparsely.

Poor.

4 m.

April 6,
1864.

Apr. 6,
1864.

Sporadic.

45 ds.

1 case.

"Westminster,
Worcester Co.

Fitchburg,
Worcester Co.

Geo. D. Colony, M.D!

March 28, 1865.
April 13, 1865.

Not known.

No preference.

1 thickly settl.
1 sparsely.

12 yrs.

July, '64
Fitchb'g

Apr. '65

Sporadic.

about
2ds.

18 h.

3ds.

"Worcester,
Worcester Co.

Benj.F. Heywood, M.D.

1 March, .

1 " 1864.
1 Feb. 21, "
1 Nov. 22, "

Not known.

No preference.

about
32 yrs.

2
15 yrs.
each.

60 yrs.

15 yrs.

Mch. —

Nov. '64

Sporadic.

3ds.
fatal.

3 w.
recov.

3 cases out of 4.

"Worcester,

Worcester Co.
Sutton,

Worcester Co.

Oramel Martin, M.D.

Jan. 1864.
Feb.
April, "

Not known.

No preference.

1 sparsely.

2 thickly.

Easy.

14 yrs.

19 yrs.

4 yrs.

Jan. '64.

1864.

Sporadic.

2 m.

2 w.

1 nev.
fully
recov.

3 cases.

Leominster,
Worcester Co.

C. C. Field, M.D.

March, 1862.

Ditto. Subject token
36 hours after arrival
from camp at Anna-
polis, where he had
been on a visit.

[See last heading.]

[See last head-
ing.]

Easy.

8 yrs.

Mch. '62

1865.

Sporadic.

8 w. to convales-
cence. . More than
yr. to full health.

1 case confined tc
back and one side
eight weeks aftei
attack before thej
ceased.

TJpton,

Worcester Co.

G.W.Ward, M.D.

April 4, 1864.

Fall.

2 yrs.

42 ds.

Upton,
Worcester Co.

C. A. Wilcox, M.D.

March 15, 1864.

Work in a hot room.

Easy.

25 yrs.

25 yr.

Sporadic.

3J ds.

3Jds.

Charlestown,
Middlesex Co.

S. H. Hurd, M.D.

April, 1864.

Not known.

Possible contagion

suggested.

No preference.

Thickly.

Poor.

8 yrs.

10 yrs.

6 yrs.

Sporadic.

about
7w.

3 w.

11 w.

2 cases.

E. Cambridge,
Middlesex Co.

Anson Hooker, M.D.

Feb. 1864.

Sporadic.

Cambridge,
Middlesex Co.

J. B. Taylor, M.D.

Dec. 1864.

Not known.

No preference.

Thickly.

Poor.

16 yrs.

20 yrs.

13 yrs.

Dec. '64

Sporadic.

10 ds.

Cambridge,

Middlesex Co.
Somerville,

Middlesex Co.

J. R. Morse, M.D.

l'Jan. 1865.
2 Mar. "
LApr. "

Not known.

One case (Mch) had

spent two days at

Gallop's Island.

Np preference.

2 on high ground,

2 on low.

Sparsely.

Easy.

11 yrs.

17 yrs.

7 yrs.

Jan. '65.

Apr. '65.

Sporadic.

13 ds.
and
10 h.

40 h.

30 ds

2 cases.

Feltonville, in Marl-
boro',
Middlesex Co.

C. W. Barnes, M.D.

Oct. 2, 1864.
Jan. 4, 1865.

Not known.

No preference.

13 yrs

16 yrs.

10 yrs.

Oct. 2,
1864.

Jan. 4,
1865.

Sporadic.

36 h.

[

60.2

ccfi

Convulsions.

No. of cases in

which they

occurred.

Headache.
No. of cases in
which it occurred.

Delirium.
Character of.

Opisthotonos
severe.

Opisthotonos
slight.

Tenderness
at Nucha.

Pulmonary and
Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

Terminat'n.

V •

° ^5

Autopsies.

Treatment.

Remarks.

4 w.

2w.

6 w.

2 cases early in the
disease.

Slight in both. Logical
answers.

Both.

Both ;

extreme in

one.

None. •

Pulse at first quick, after-
wards normal.

In 1 case a few petechias on
chest and abdomen.

XXI.

8h.

con-
vales.

8h.

con-
vales.

8h.
to

con-
vales.

8 times an hour
on an average.

1 case.

Constant for eight hours.
No answers.

Very
severe.

•

Respiration exces-
sively labored.

Pulse veiy small and
rapid.

The right half of the body
completely covered with pete-
chias; the division on the face
was perfect ; on the back and
side the eruption was purple,
also on the forehead. As soon
as the patient began to improve,
the eruption began to subside,
and in 24 hours completely
disappeared.

xxn.

45 ds.

1 case.

Unknown.

Constant.

Not observ'd

None.

None observed.

Nausea and
constipation.

No petechia? or other morbid
appearance could be found.

Calomel and soda only.

about
2ds.

18 h.

3ds.

Severe in both.

More or less in both,
with gradual loss of con-
sciousness. Questions
answered during first
■ stage.

Both.

In 1, respiration hur-
ried and painful.

Heart's action violent ;

pulse rapid and full

in both cases.

Dark spots in both, rapidly
increasing — in one closely
resembling measles in shape.
In one case, over body general-
ly, in the other confined to
extremities and petechial.

XXIII.
0

Stimulation.

3ds.
fatal.

3w.

recov.

3 cases out of 4.

Severe in all 4.

[n 3 out of the 4. Logical

answers in 2. Delirium

low muttering.

In all 4.

Not noticed.

Pulse 90 to 100.

Nausea and
vomiting at
commence-
ment.

Not marked.

XXIV.

2 m.

2w.

1 nev.
fully
recov.

3 cases.

3 cases back part
of head.

In all 3. Seemed idiotic.
No logical answers.

1
decubitus
abdominal.

In all 3.
Also pain in-
creased by
motion.

Petechia; in all.

XXV.

8 w. to convales-
cence. . More than
yr. to full health.

1 case confined to
back and one side ;

eight weeks after

attack before they

ceased.

1 case.

Constant for two weeks.
Logical answers seldom.
Delirium low muttering.

1 prolonged.

Pneumonia in third
week for a week.

Pulse 120.

Skin mottled— dark spots on
different parts of the body.

XXVI.

42 ds.

Not remembered.

1 case.

Slight, but
continuous.

Petechias.

3£ds.

3Jds.

3Jds-

Severe, and

oaroxysmal at back

part of head.

1 case. Logical answers.
Delirium low muttering.

1 case disp.
to throw
head back.

1 case,
also pain.

Pulse weak, rapid,
variable.

Constipation

None.

XXVII.

about
7w.

3 TV.

11 w.

2 cases.

Constant in both
cases.

2 cases. Logical answers.

2 cases.

Pulse rapid and feeble.

Petechias very marked in both.

Expectant.

1 case.

Petechias.

10 ds.

Severe in both.

None.

1 case.

Pulse very l'apid.

Not marked.

Narcotics, stimulants,
local bleeding, tonics.

13 ds.
and
10 h.

40 h.

30 ds.

2 cases.

Severe in all 4.

3 cases. Logical an-
swers in one case of the
3 delirious.

2 cases.

In all 4.

Obstinate

constipation

in 1 ease.

Petechias in 2 cases, darkish

brown, remained only a few

hours.

Diffusible stimulants

and alteratives, tonics,

counter-irritants.

1 fatal, 30 days.
1 " 40 hours,
1 recovered, 10 days.
1 " 12 days.

36 h.

1 severe till death ;
1 for first 12 hours.

1 only— logical ans.

1 case.

Not noticed.

XXVIII.

[

B 3

NAMES OF TOWNS.

Names of Reporters.

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts

thickly or

sparsely settl'd

Condition
of Patients.

to
<

"9
■a

Op Adults.

Adv. Mid.
Age. Age.

"o
<

o a
a 3
b«

9
ho

-3

60
<

■a

H S b

u * o o
*i c a °-

d H b

<* * 9 H

3 .55
s P s S

JO»H

i I

£8§

" 3

V, OS

cofi

Convulsions.

No. of cases in

which they

occurred.

Westfield,
Hampden Co.

Geo. G. Tucker, M.D.

8 winter and

spring of 1858.

8 from '61 to '65.

Wholly dry and
high.

Country 'town.

Sparselyi

See
"Re-

mks."

38 yrs.

2Jm.

See
"Re-
mks."

Feb. '57.

Epidemic.

12 h.

3 m.
Fatal.

Spasmodic action
frequent.

Westfield,
Hampden Co.

J. G. Abbott, M.D.

1859.

ditto.

Spafsely.

Easy
circumstances.

about
35yrs.

50 yrs.

30 yrs.

4ds.

Greenfield,

Franklin Co.
Westfield,

Hampden Co.
Springfield,

Hampden Co.

W. G. Breck, M.D.

3
5
10

1864.

1861.

2 in '62 ; 3 in '63 ;

3 in '64 (Men. and

Apr.) ; 2 in '65.

Not known.

No preference.

Say
15 yrs.

See
" Re-

mks."

35 yrs.

5 yrs.

Of 10

cases

Sprigf
6

Springf.
1862.

Springf

April,

1865.

Epidemic.
Sporadic.

3 m.

lm.

8 m.

A frequent
occurrence.

Springfield,
Hampden Co.

M. Calkins, M.D.

March, '65.

Not known.

Damp.

Thickly.

Poor.

Say
35 yrs.

Feb. '65.

Apr. '65

Sporadic.

2w.

"Cramps!" in the
arms and hands.

Monson Almshouse,
Hampden Co.

J. D. Nichols, M.D.

17th and 18th
May, '65.

Not known.

No preference.

Almshouse on
a hill by

itself.

Almshouse.

5 yrs.

7 yrs.

3 yrs.

Epidemic
in town.

0
In wards
distant
inter se.

25 h.

24 h.

26 h.

2 cases.

Monson,

Hampden Co.
Palmer,

Hampden Co.

Wm. Holbrook, M.D.

Feb. 9 to Mch. 5,
1865.

Not known.

No preference.

8 yrs.

Chief-
ly.

21 yrs.

18 m.

Feb. 9,

1865.

Palmer.

Mar. 5,

1865.

Palmer.

Epidemic.

about
24 h.

12 h.

5 w.

Most of the cases ;
some early, others
late in the disease.

Palmer,

Hampden Co.
Monson,

Hampden Co.

Samuel Shaw, M.D.

12
2

Feb. 10 to Apr. 1,
1865.

Not known.

No preference.

20 yrs.

10 fr.
7-12
yrs.

35 yrs.

5 yrs.

2 cases
1858.

Apr. 4,
1865.

Epidemic.

5ds.

22 h.

7ds.

Athol,
Worcester Co.

J. P. Lynde, M.D.

2 in March,
1 in April,
1 in Dee., 1864.
1 in Jan. 1865.

Not known.

No preference.

about

10 yrs.

14 yrs.

7 yrs.

Mch. '64

Aug. '65

Sporadic.

39 h.

24 h.

52 h.

2 cases. In one

early, in the

other late in the

disease.

Athol,
Worcester Co.

Ditto (additional).

Aug. 1865.

6 m.

6 ms.

6 m.

Sporadic.

31 h.

Petersham,
Worcester Co.

F A. Wood, M.D.

1864.

Not known.

The whole town is
high.

Sparsely.

No preference.

11 yrs.

Chief-
ly-

18 yrs.

2 yrs.

Mch. '64

Aug. '64

Sporadic.

Say
34 ds.

3ds.

4ds.

All 4 cases.
With outcries
In every case.

Bana,

Worcester Co.
New Braintree,

Worcester Co.
Hardwick,

Worcester Co.

Almon M. Orcutt, M.D.

1
9

Hardwick,
Feb. 16, 1864,
Feb. 18, "
Mch. 3, "

:: ii9; :

8, "
Feb. 12, 1865,
« l7> .,

Apr. 21, "
Dana, Mch. 1, '64.
N. Braintree, Apr.
26, 1864.

Not known.

No preference.

Sparsely.

No preference.

27 yrs.

No
pref.
betw.
adults

and
child-
ren.

53 yrs.
35 yrs.

6 yrs.

Feb. 16,
1864.
Hard-
wick.

Apr. 21,
1865.

Hard-
wick.

Epidemic.

18 ds.

5ds.

45 ds.

New Braintree.

Worcester Co.
Oakham,

Worcester Co.
North Brookfield,

Worcester Co.

S. P. Martin, M.D.

2 •
1

Mch. 2, 1864.
" 23, "
" 14, "

Oct. 13, "

Not known.

No preference.

Sparsely.

4 easy circum.

about
32 yrs.

0 yrs.

March,

1864.

New Br.

Sporadic.

about
18 ds.

2ds.

38 ds.

4 cases. Most fre-
quent in the
2 children.

Several complained
of severe head-
ache ; others
but little.

Headache.
No. of cases in
which it occurred.

Frequent.

Constant and
severe.

Severe, principally

in the occipital

region.

Severe in all 5, in
forehead.

Severe in all ;

' terrible " in 3

fatal cases.

All 4, but not
severe.

[

I* 3

T» o

8 3

Convulsions.

No. of cases in

which they

occurred.

Headache.
No. of cases in
which it occurred.

Delirium.
Character of.

Opisthotonos Opisthotonos

severe. slight.

Tenderness
at Nucha.

Pulmonary and

Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

rBRMINAT'N.

1 i

Autopsies.

Treatment.

Remarks.

12 h.

3 m.

Fatal

Spasmodic action
frequent.

Frequent.

Generally occurred.

Logical answers in those

not suddenly attacked.

In eases of sudden

invasion, no.

Say 6 cases.

Say 10 cases.

i. e. some

in all.

Slight bronchal irri-
tation, and conges-
tion in some cases.

None well marked.

Costiveness.

Slight

diarrhoea,

flatulence in

s6me.

Not mentioned.

8
See XI.

XI.

XI.
Young lads for most part.

4ds.

XII.

lm.

8 m.

A frequent
occurrence.

Constant and
severe.

More or less in every

casei Logical answers

occasionally.

In every
case.

Not observed.

Pulse various.

In every case petechias, being

purple or copper-colored,

from size of a pin's head to

that of a half dollar.

"is

Ss-B

* w

Spr. 4

Spr. 6

xm.

xin.

3 cases in Greenfield, adults.
5 in Westfield, children and

adults.

10 in Springfield, under 12 yrs.

XIII.

2 w.

2w.

" Cramps!" in the
arms and hands.

Severe, principally

in the occipital

region.

Slight.

Great sore-
ness, stiff-
ness and

tenderness.

xrv.

24 h.

26 h.

2 cases.

Both patients comatose.

Petechise in 1 case.

Counter-irritants to the
spine — veratrnm viride.

12 h.

5 w.

Most of the cases ;
some early, others
late in the disease.

Several complained
of severe head-
ache ; others
but little.

More or less in nearly

all the Cases. Logical

answers sometimes,

at other times comatose

state.

Opisthotonos in nearly
all. 1 or 2 only slightly.

Hurried respiration,
as a general statem't.

Pulse rapid, increasing
to 150 and 175.

None had petechise during life ;

after death 2 or 3 had spots like

purpura, and 1 or 2 had a

purple or leaden color.

XV.

22 h.

7ds.

In all.

In all the cases not
relieved in the first 24
hours. Logical answers.

2 cases.

4 cases.

Say 10 cases.

Pulse wiry, very rapid,
often 150.

No petechia during life. In 1

case discoloration of the skin

after death.

XVI.

24 h.

52 h.

2 cases. In one

early, in the

other late in the

disease.

Severe in all 5, in
forehead.

In all 5 cases. Logical
answers for a time ; after-
wards stupor.

1 case.

2 cases.

Not obscrv'd

and not
looked for.

Respiration hurried
and sighing.

Pulse very rapid, sharp

and feeble. Action of

heart " feeble and

oppressed."

Vomiting.

Skin livid or purple,pufly. Erup-
tion of rose spots or petechise,

size of split pea ; pur. not disap.
on pres. — over trunk and extr.

Expectant, supporting,
stimulating.

31 h.

Respiration exces-
sively hurried.

Pulse very rapid.

Vomiting.

Skin livid and purple — at first,
cold.

XVII.

Stimulating.

3ds.

4ds.

All 4 cases.
With outcries
In every case.

All 4 cases.

In all 4 cases. Logical

answers in only 1 case.

That recovered.

In all 4.

in 3 cases.

Pulse not mentioned.

Vomiting
generally in
first stage.

No spots.

XVIII.

5ds.

45 ds.

Severe in all ;

" terrible " in 3

fatal cases.

In all 11 cases. In the

8 recoveries, logical

answers. In one of

the fatal cases also. In

the other two fatal cases,

no logical answers.

In all 3

fatal cases.

In all 8
recoveries.

In all

11 cases.

More or less frothy

expectoration, with

occasional "bastard

pleurisy."

Pulse in early stage fee-
ble ; in stage of re-action,
fuller, but not very
frequent.

Vomiting in
all. Consti-
pation, with
retention or
suppression
of mine,
frequent.

Spots not particularly marked.
Where any portion of the body

rested upon the bed-clothes

there would be a spot. In the

earlier stages of the 3 fatal cases

the skin had a mottled

appearance.

XIX.

1 relapse, fatal. Robust and

feeble had the same appearance

soon after attack.

2ds.

38 ds.

4 cases. Most fre-
quent in the
2 children.

All 4, but not
severe.

All more or less.
All gave logical answers.

3 cases ;
1 adult,
2 children.

All 4.

Pulse in the 2 children
rapid, and feeble in the
2 adults— from 80 to 100.

XX.

[

a. ;

NAMES OF TOWNS.

Names of Reporters.

'£
o

Their Dates.

Sources of the
Disease.

Locality.

High or low, damp

or dry.

Districts
thickly or

sparsely settl'c

Condition
of Patients.

60
<

Of Adults.

Adv. Mid.
Age. Age.

1
<3
"o
■a

u
o

1 &

1
1

to
<

■a

First case in

Town, so far

as known by

Reporter.

Last casein

Town, so far

as known by

Reporter.

SS'B a

cofi

In O

Convulsions.

No. of cases in

which they

occurred.

Headache.
No. of cases in
which it occurred.

Becket,
Berkshire Co.

E. G. Wheeler, M.D.

Apr. 5, '57,-1 case

7, 1
Oct. 31, 1
Mch. 6 to 14, '58,

5 cases.

Not known.

Six cases in a hol-
low where 3 small
streams'meet; seven
milldams in village.
Two cases high
and dry.

No preference.

All in easy
circumstances.

about
4

45 yrs.

5 m.

Apr. 5,
1857.

Mar. 14,
1858.

In 1857,
sporadic.

In 1858,
epidemic.

Less
than
3ds.

12 h.

3ds.

All 8 cases.

Violent in all who

were sensible —

7 cases.

Pittsfield,

Berkshire Co.
Adams,

Berkshire Co.
Hinsdale,

Berkshire Co.

Wm. W. Greene, M.D.

5
1

In 1863 1 case.
6 cases '64 to '65.

Not known.

No preference.

25 yrs.

Chief-
ly.

45 yrs.

2iyrs.

Feb. '63.
Pittsfi'ld

June '65
Pittsfi'ld

Sporadic.

About
15 ds.

2ds.

21 w.
to con-
vales.

In 4 out of the 7 :
i. e. in all the child-
ren and 1 adult.

In aU 7.

Shutesbury,

Franklin Co.
Leverett,

Franklin Co.
Belchertown,

Hampshire Co.
Amherst,

Hampshire Co.

David Rice, M.D.

1
1
1
1

1 in Ap., 1 in May,
2 in June, 1865.

Supposed to be the
same as those
of diphtheria.

No preference.

Sparsely.

All in easy
circumstances.

40yrs.

Chief-
ly-

65 yrs.

35 yrs.

June '65
Leverett

Sporadic

3w.

3 w.

Severe pain in

the head of all 4,

extending down

the spine.

Montague,
Franklin Co.

D. Bradford, M.D.

Jan. 13, 1864.

Exposure to cold
nights.

Hight dry.

Sparsely.

Poor.

18 yrs.

Jan. 13,
1864.

Sporadic.

5ds.

Prescott,
Hampshire Co.

David Rice, M.D.

July, 1865.

Patient, a physician ;
saw a case of the
disease two weeks
before his attack.

High and dry. Ty-
phoid fever pre-
vails much.

Village,
sparsely.

Easy
circumstances.

38 yrs.

Sporadic.

Yes ?

See

Sources.

2w.

2W;

Severe pain in
head, and extend-
ing whole length
of spinal column.

Heath,

Franklin Co.
Rowe,

Franklin Co.
[Whitingham, State of
Vermont.]

C. Temple, M.D.

1
1

Feb. 1 to July 1.
1861.

Not known.

ftigh.

Sparsely.

No preference.

28 yrs.

chief-
ly;

Chief-
ly.

55 yrs.

11 yrs.

Feb. '64.

Apr. '64.

Epidemic.

19 ds.

4ds.

60 ds.

In all 4
very severe;

Westfield,
Hampden Co.

James Holland, M.D.

Jan. '58, 1 case.
Feb. 5
Mch. 3
Apr. 3
Jan. '65, 1
Feb. 1
Mch. 1
Apr. 1
July 1

" Some peculiar con-
dition of the atmos-
phere" in 1858.
In 1865, the 5 cases
traceable to over-ex-
ertion and exposure
to cold and wet.

No preference;

No preference.

19 yrs.

Of 12,
ch'fly

adults.

72 yrs.

11m.

The 12

in '58

not

men-

tion'd.

In '65
4

In '65.
1

Jan. '58.

July '65.

In 1858,
epidemic.
In 1865,
sporadic.

About
33 ds.

20 h.

163 ds

Severe pain iii
head, and extend-
ing down neck and
back, in every case
where the sufferer
could speak;

Williamsburg,
Hampshire Co.

W. M. Trow, M.D.

Dec. 4, 1863.

Not known.

No preference;

Village,
sparsely.

Easy
circumstances.

39 yrs.
about.

39 yrs.

Dec. 4,
1863.

Sporadic.

36 h.

38 h.

Very severe.

. Northampton,
Hampshire Co-.

A. W; Thompson, M.D.

Feb. 27 to April
28, 1864.

Contagion supposed,
except the first case.

Low and damp-.

Medium.

Poor.

33 yrs.

50 yrs.

23 yrs.

Feb. 27,
1864.

Apr. 28,
1864.

Sporadic.

Yes.

3w.

2 w.

4W.

In 6 cases, iii one
intense.

Granby,

Hampshire Co.
Ludlow,

Hampden Co.
Belchertown,

Hampshire Co.

L. E. Marsh, M.D.

12
1
2

1 in Oct. 1862.

1 Apr. 1864.

2 Mch. 1865.

2 Feb.

3 Apr. "
3 May, "
1 June. • "
1 July, "
1 Aug. "

Theory of poison in
atmosphere.

.No preference;

No preference.

The
adults
most-
ly.

Chief-
ly.

45 yrs.

4 m.

7 .

Oct. '62.
Granby.

Aug. '65
Granby.

Sporadic.

8ds.

24 h.

6 w.

In 2 cases.

Violent in every
case.

Greenwich,
Hampshire Co.

J. W. Goodell, M.D.

1 Jan. 19, 1865.
1 24, "
1 28, "

1 29, "

2 Feb. 3, "

i s, "

Not known. Fol-
lowed severe cold
weather.

Dry plain.
See " Remarks."

Sparsely.

Easy
circumstances.

19 yrs.

The

ddults
most-
ly-

Chief-
ly-

63 yrs.

2 yrs.

Jan. 19,
1865.

Feb. 5,
1865.

Epidemic.

about

4d.

12 h.

7ds.

Say 5 in back of
head.

[ -^

]

)

£3

o» O

° 3

g§

C5«

Convulsions.

No. of cases In

which they

occurred.

Headache.
No. of cases in
which it occurred.

Delirium.
Character of.

Opisthotonos
severe.

Opisthotonos
slight.

Tenderness
at Nucha.

Pulmonary and
Pleural Symptoms.

Cardiac.

Abdominal.

Morbid Appearances
of the Skin.

Terminat'n.

1 1

Autopsies.

Treatment.

Remarks.

Less
than
3ds.

12 h.

3ds.

All 8 cases.

Violent in all who

were sensible —

7 cases.

In all 8 cases — wild in 1.

In the other 7 cases,

logical answers till coma

set in.

6 cases.

2 cases.

In 5 cases ;
the others
unconscious
when seen.

In 2 cases respira*

tion laborious and

irregular.

In 6 cases, pulse feeble,

frequent, thready. In 2

some " reaction."

In 3 cases,
severe pain
in bowels,
and vomiting
at outset.

Petechia; in all, and great sen-
sibility and soreness of the
cutaneous surface.

None.

About
15 ds.

2ds.

21 w.

to con-
vales.

In 4 out of the 7 :
i. e. in all the child-
ren and 1 adult.

In all t

In 5 out of the 7. 4 out

of the 5 gave logical

answers.

6 out of 7.

1 out of 7.

In all
extreme.

None marked. 0

Pulse rapid, sufficiently
strong.

In all but 1, 6 out of 7, irregu-
larly shaped spots, varying in
size from a millet seed to a split
bean ; rose color or darker ; not
disappearing on pressure.

3
See II.

II.

3w.

3 w.

Severe pain in

the head of all 4,

extending down

the spine.

Mild delirium, tending

to comaj in 1 case
only. Logical answers.

In all.

Difficult respira-
tion in 4. Pain in
chest in 1.

"Pulse in one, 40 for seve-
ral days, with coma and
much irregularity."

III.

5ds.

Delirium most of the

time. Logical answers

occasionally.

Cough.-

Pulse 100 to 125.

Petechias last 3 days, and at

death livid or purplish spots,

mostly on trunk.

rv-

2 w.

2w.

2#.

Severe pain in
head, and extend-
ing whole length
of spinal column.

Obtuseness of intellect

with disposition to coma.

Could be roused at any

time.

1 great.

Pulse very variable.
40 to 100.

Revulsives, epispastlcs,
stimulants, tonics.

Convalescence slow.

19 ds.

4ds;

80 ds.

In all 4
very severe;

In all 4. Logical an-
swers in one only;

Pulse small, frequent,
hard.

All 4 cases petechias. In 3 ap-
peared the 2d day on the body,
but little on the limbs. In the
other case only on the back,
and Were of a very dark
purple color.

The cases in Whitingham, Vt.,

cannot be separated from the

others in the answers to the

Circular.

See also V.

About
33 ds.

20 h.

163 ds

Severe pain in
head, and extend-
ng down neck and
back, in every case
where the sufferer
could speak;

Delirium present more
or less in all the 17 cases.
Its character was very
variable. For the most
part, however, shown in
low muttering. Logi-
cal answers generally.

In all the 12
cases of '58.
Not menti'n-

ed in those
of 1865. See

"remarks."

Slight
in no case.

In all more
or less.

In most cases, con-
striction at chest ; res-
piration often hurried
and laborious. In no
case were the lungs
or pleurae involved.

No morbid changes in
heart before or after death
In first stage, pulse rapid;
small, and In many cases

imperceptible. After-
Wards variable.

Sense of
constriction;

In every case in '58 ; none in '65.
Bright, red spots after a few h.,
becoming purple or livid, on
face; neck, trunk and limbs ; nu-
merous in most cases ; form ir-
regular ; size from 2 to 12 1. dia.
not raised. In 1 case spots dis-
ap. end of 3d w. but on 7th w.
returned in greater num. This
patient, a boy of 9 y. died 10th w.

In '58,
11 out
of 12
died.

In '65
3 out
of 5
died.

VI.

5 relapses, 3 of them fatal.
The 5 cases in 1865, children.

36 h.
3w.

36 h.

36 hi

Very severe.

Brief.

Pulse very small and
frequent.

Alterative and stimulant.

VII.

2 w.

4W.

In 6 cases, in one
intense.

In 2 out of 6 cases,

active; In 1, no logical

answers.

1 fol. by

paralysis of

muscles of

neck.

Prleumonia in 4,

pleuro-pneumonia

in 1.

Pulse rapid In 4 cases.

1 tympanites

Petechias in 3 cases. In one, face
ind neck, dark mahogany color,
idbking as if " struck witli a nut-
meg grater." Spots desq. lividity

viii.

VIII.

8ds.

24 h.

In 2 cases.

Violent in every
case.

In almost all the cases ;

generally low muttering.

Logical answers in

almost all.

Say 3 cases.

Say 10 cases.

In nearly all.

Say 7 cases. .
See "Remarks.'*

t*ulse extremely rapid
in all. Frorh 120 to 200.

Nausea in
1 case.

In say 7 cases, spots like those
in typhoid fever.

IX.

about
4d.

12 h.

7ds.

Say 5 in back of
head.

2 cases, logical answers
at times.

In 1 only— in that
well marked pneu-
monia 3 days before

any symptom of

meningitis.

Heart's actidri very feeble.

Pulse fluttering and

intermittent.

In 6 cases
bowels cos-
tive. Vomit-
ing & purg-
ing in other.

Petechia; well marked in all.

I
I

■

•

■

CEREBROSPINAL MENINGITIS. 67

RESULTS OF THE TABLES.

Berkshire County.*

The towns from which affirmative replies have been receiv-
ed, are : Adams, 1 case, population 6,924 ;f Becket, 8 cases,
population 1,518 ; Hinsdale, 1 case, population 1,511 ; Pitts-
field, 5 cases, population 8,045.

No. of above towns, 4

" " towns negatively reported, 5

" " " unheard from, 22

Whole No. of towns in County, 31

Proportion of towns affirmatively reported, to

the number of towns in the County, about -|
No. of cases reported from County, 15

Population of County, 55,120

Proportion of cases reported, to population of

County, about 1 in 3,674

Franklin County.

The towns from which affirmative replies have been receiv-
ed, are : Greenfield, 3 cases, population 3,198 ; Heath, 1
case, pop. 661 ; Leverett, 1 case, pop. 964 ; Montague, J 1
case, pop. 1,593 ; Rowe, 1 case, pop. 619 ; Shutesbury, 1
case, pop. £98.

* Dr. Babbitt, of the Committee, writes (since these calculations were com-
pleted) that there is but little knowledge of the disease in the County; but re-
ports two additional cases in the hands of an irregular practitioDer in Adams.

f The statements of population are on the basis of the census of 1860.

% Five additional cases in Montague in 1864, reported since these calculations
were made^ will be given hereafter.

68 REPORT.

No. of above towns, 6

" " towns negatively reported, 4

" " " unheard from, 16

Proportion of towns affirmatively'reported, to

whole No. of towns in County, between \ and -J
No. of cases reported from County, 8

Population of County, 31,434

Proportion of cases reported, to population of

County, as 1 in 3,929

Hampshire County.*

The towns from which affirmative replies have been recer
ed, are : Amherst, 1 case, pop. 3,206 ; Belchertown, 3 cases
pop. 2,709 ; Granby, 12 cases, pop. 907 ; Greenwich, 7 case;
pop. 699 ; Northampton, 6 cases, pop. 6,788 ; Prescott,
case, pop. 611 ; Williamsburg, 1 case, pop. 2,095.

No. of above towns, 7

Indirectly reported (Hadley) affirmative, 1

No. of towns negatively reported, 2

" " " unheard from, 13

Proportion of towns affirmatively reported, to

the whole No. of towns in the County, about ^

No. of cases directly reported from County, 31
Population of County, 37,823

Proportion of cases reported, to population of

County, as 1 in 1,220

* Four cases were received May 25, 1866 (after the completion of the report
which occurred in South Hadley and Granby, December, 1864, March, 1865, an
January, 1866. See Appendix.

CEREBROSPINAL MENINGITIS. 69

Hampden County.

The towns from which affirmative replies have been receiv-
ed, are : Monson, 5 cases, pop. 3,164; Palmer, 20 cases,
pop. 4,082 ; Springfield, 11 cases, pop. 15,199; Westfield,
41 cases, pop. 5,055 ; Ludlow, 1 case, pop. 1,114.

No. of above towns, 5

Indirectly reported (Russell) affirmative, 1

No. of towns negatively reported, 4

" " " unheard from, 11

21
Proportion of towns affirmatively reported, to

whole No. of towns in County, between -i and J
No. of cases directly reported from County, 78

Population of County, 57,366

Proportion of cases reported, to population

of County, as 1 in 735

Worcester County.

The towns from which affirmative replies have been receiv-
ed, are : Athol, 6 cases, pop. 2,604 ; Barre, 1 case, pop.
2,973 ; Brookfield, including East Brookfield, 2 cases, pop.
2,276 ; Dana, 1 case, pop. 876 ; Fitchburg, 1 case, pop. 7,805 ;
Hardwick, 9 cases, pop. 1,521 ; Leicester, 1 case, pop. 2,748;
Leominster, 1 case, pop. 3,522 ; New Braintree, 2 cases,
pop. 805 ; North Brookfield, 1 case, pop. 2,760 ; Oakham,
2 cases, pop. 959 ; Petersham, 4 cases, pop. 1,465 ; Sutton,
1 case, pop. 2,676 ; Upton, 2 cases, pop. 1,986 ; Westmin-
ster, 1 case, pop. 1,840 ; Worcester, 6 cases, pop. 24,960.
No. of above towns, 16

" " towns negatively reported, 16

" " " unheard from, 26

70 REPORT.

Proportion of towns affirmatively reported, to

whole No. of towns in County, between % and J
No. of cases reported from County, 41

Population of County, 159,659

Proportion of cases reported, to population of

County, as 1 in 3,894

Middlesex County.

The towns from which affirmative replies have been receiv-
ed, are : Billerica, 2 cases, pop. 1,776 ; Cambridge, including
East Cambridge, 5 cases, pop. 26,060 ; Charlestown, 2 cases,
pop. 25,065 ; Marlborough, 2 cases, pop. 5,911 ; South
Reading, 2 cases, pop. 3,207 ; Somerville, 2 cases, pop. 8,025.
No. of above towns, 6

" " towns negatively reported, 32

Doubtful report from Framingham, 1

Towns unheard from, 13

Proportion of towns affirmatively reported, to

whole number of towns, about J-

No. of cases reported from County, 15

Population of County, 216,354

Proportion of cases reported, to population of

County, as 1 to 14,423

Essex County.

The towns from which affirmative replies have been receiv-
ed, are : Amesbury, 1 case, pop. 3,877 ; Boxford, 1 case,
pop. 1,020 ; Danvers, 1 case, pop. 5,110 ; Lynnfield, 1 case,
pop. 866 ; Topsfield, 1 case, pop. 1,292.

No. of above towns, 5

Indirectly reported affirmative, by Georgetown, 1

6
Doubtfully reported, Haverhill, 1

CEREBROSPINAL MENINGITIS. 71

No. of towns negatively reported, IT

" " " unheard from, 10

Proportion of towns affirmatively reported, to

whole number of towns in County, between -J- and £
No. of cases directly reported from County, 5

Population of County, 165,611

Proportion of cases reported, to population

of County, as 1 in 33,122

Norfolk County.

The towns from which affirmative replies have been receiv-
ed (excluding Brookline, with 1 cases occurring in 1866),
are : Dorchester, 1 case, pop. 9,169 ; Medfield, 1 case, pop.
1,082; Roxbury, 3 cases, pop. 25,131; Walpole, 1 case,
pop. 2,031 ; West Roxbury, 1 case, pop., 6,310 ; Weymouth,
1 case, pop. 1,142.

No. of above towns, 6

" " towns negatively reported, 13

" " " doubtfully " (Needham) 1

Towns unheard from, 3

Proportion of towns affirmatively reported, to

whole number of towns in County, between ^ and J
No. of cases reported from County, 8

Population of County, 109,950

Proportion of cases reported, to population

of County, as 1 in 13,144

Bristol County.

The towns from which affirmative replies have been receiv-
ed, are : Fairhaven, 6 cases, pop. 3,118 ; New Bedford, 2
cases, pop. 22,300.

No of above towns, 2

" " towns negatively reported, 1

72 REPORT.

No. of towns unheard from, 11

Proportion of towns affirmatively reported, to

whole number of towns in County,
No. of cases reported from County, 8

Population of County, 93,794

Proportion of cases reported, to population

of County, as 1 in 11,124

Plymouth County.

The only town from which an affirmative reply has been
received is Carver, 1 case, pop. 1,186.

No. of above 1

No. of towns negatively reported, 17

" " " unheard from, 7

i ,

2 5

Proportion of towns affirmatively reported, to

whole number of towns in County,
No. of cases reported from County, 1

Population of County, 64,768

Dukes County.

Towns affirmatively reported, 0

" negatively " 2

" unheard from, 2

Population of County, 4,403

Nantucket County.
Eeply negative. Population, 6,094

Barnstable County.

The only town from which an affirmative reply has been
received, is Barnstable, 2 cases, pop. 5,129.

CEREBEO-SPINAL MENINGITIS. 73

No. of above, 1

" " towns negatively reported, 7

" " " unheard from, 5

Proportion of towns affirmatively reported, to

whole number of towns in the County, yV

No. of cases reported from County, 2

Population of County, 35,990

Proportion of cases reported, to population of

County, as 1 in 11,995

Suffolk County.

The only town from which an affirmative reply has been
received, is Boston, 43 cases, pop. 177,840.

No. of above, 1

" " towns negatively reported, 2

" " " unheard from (N.Chelsea, pop. 921), 1

Proportion of towns affirmatively reported, to

whole number of towns in- County, J

No. of cases reported from County, 43

Population of County, 192,700

Proportion of cases affirmatively reported, to

population of County, as 1 in 4,481

In the State of Massachusetts,

The number of towns from which affirmative replies have

been received previously to January 1, 1866,* including

those indirectly reported, is 63

No. of towns negatively reported, 129

" " " doubtfully " 3

" " " unheard from, 140

335

* Brookline, in Norfolk County, is excluded because its cases occurred in 1866,
while the reports from other towns came in during the previous year.

74 REPORT.

«
Proportion of towns affirmatively reported to

whole number of towns in the State, is

very nearly 19 per centum, or about -J-

No. of cases reported from all the towns of

the State, except Brookline* 255

Population of State, 1,231,066

Proportion of cases reported (as above) to

population of State, as 1 in 4,827

Population of State, 1,231,066 ; minus popu-
lation of Suffolk County, 192,100 =1,038,366

Cases in the State as above, 255 ; minus 43

cases in Suffolk County =212

Proportion of cases in the State previous to
January 1, 1866, excluding1 those in Suffolk
County, to the population of the State, ex-
cluding- that of Suffolk County, about as 1 in 4,898
(1,038,366-^-212.)

Total number of cases in the toivns of the

State up to January 1, 1866, 255

Cases in Brookline, Norfolk Co., January 1, 1866, 7
Cases in Boston Harbor, Gallop's Island, 19

Fort Warren, 4

Fort Independence, etc., 0

285
Cases in Whitingham, Vermont, 2

Total number of cases in the tables, 287

We will state here, that besides the affirmative replies from
Suffolk County, recorded in the above tables, there were 108
negative answers from that County.

* See note on page 73.

CEREBROSPINAL MENINGITIS. 75

SOME GENERAL RESULTS OP THE PRECEDING

STATISTICS.

The present epidemic in Worcester County is represented
by a number of the same towns in which the epidemic of
1806 to 1815 occurred. The town of Dana, where the last
mentioned began in that County, had one case in 1864.
Both epidemics, also, rested upon the towns of Petersham,
Barre, Oakham, Hardwick, New Braintree, Brookfield, Athol,
Leicester, and Worcester. " Gerry," mentioned in the ac-
count of the old epidemic, is now an obsolete name. Paxton,
Rutland, Spencer, Sturbridge, and Winchendon, sufferers in
the old, do not appear in the present epidemic.

Medfield, in Norfolk County, historical as the first starting
point of the " old spotted fever,7' is represented by one case
in 1865. In Cambridge, Middlesex County, the present epi-
demic has differed from the old, in that it has not selected
the marshy portions of Cambridgeport.

It is, perhaps, worthy of mention, that Middlesex County,
though in great part inland, does not seem to have suffered
much in the old epidemic, and has felt the present one but
lightly.

In reviewing the foregoing statistics, it strikes us that
there is not a material difference between the proportion of
cases to population in Suffolk County, and the proportion of
cases to population in the rest of the State. As Suffolk
County means Boston, and its more immmediate suburbs —
the latter peopled much in the same manner as itself — we
learn from the above fact, that the disease in question has
not sought out the metropolis especially for its ravages. On
the contrary, inspection shows us that the places where
the malady has dealt its heaviest blows, are the country
towns of the interior of the State ; as, for instance; lx

76 REPORT.

Hampden County, where the ratio of cases is 1 to 135 inhabi-
tants, while that of Suffolk County is 1 to 4,481. Or, again,
contrast the ratio of Boston alone (1 to 4,136) with that of
the town of Westfield, in Hampden County, which is 1 in
123 ; the number of cases in the city with its 117,840 inhabi-
tants being- 43, while that of the country town with its 5,055
inhabitants is 41. Another less striking instance is that of
Palmer with its 20 cases among 4,082 inhabitants, or 1 in 204.

The ratio of Suffolk County, however, is much greater than
that of the other eastern Counties, not diverging very widely
from the ratio of the inland County of Worcester.

A survey of the statistics of the different Counties inter se,
from west to east, gives the following results. We begin at
Berkshire County, with a moderate figure — 1 in 3,614, and
meet a ratio in Franklin County, which as entered in the
tables, was 1 in 3,929. This ratio has been raised by the
reception of 5 additional cases from Montague to 1 in 2,418.
In Hampshire County — next south of Franklin — the ratio
rises to 1 in 1,220 ; and in Hampden County, next south of
Hampshire, to 1 in 135. These three last-mentioned Coun-
ties form the eastern border of Berkshire. Bounding them,
on the east lies the large County of Worcester, in which the
ratio corresponds more nearly with that of Berkshire County,
being 1 in 3,894. Passing to the east, we reach the eastern
Counties, all of which touch the waters of the Atlantic at one
or more points. In these, the ratio drops abruptly, being in
Middlesex 1 in 14,423. Yet Middlesex is more thoroughly
reported than most Counties.

In Norfolk County the ratio is not far from that of Middle-
sex, being 1 in 13,144. In Essex County, lying largely upon
the sea, the ratio drops again to 1 in 33,122. In Bristol
County, touching the ocean only on its southern border, it
rises to the neighborhood of that of Norfolk, which has about
an equivalent Atlantic exposure. In Plymouth County, with
some three-fourths of its boundary consisting of sea-shore,
the ratio drops to 1 in 64,168.

In Dukes, Nantucket, and Barnstable Counties, all well

CEREBROSPINAL MENINGITIS. 77

out at sea, the replies are, for the two former, no cases ; for
the last, 2 cases — or 1 in 35,990.

It happens, then, that so far as our reports inform us, the
eastern Counties have had, according to their population, less
of the disease than the others ; and have felt it just about in
an inverse proportion to their exposure to the sea.

Does Proximity to bodies of Fresh Water favor the Inva-
sion of the Disease ?

Glancing at the map of the State to see if any of its other
features may be associated with the special prevalence of
the disease, the eye falls upon the Connecticut River, to find
it traversing the three Counties having the largest proportion
of cases reported. We look to Westfield with its heavy list
of 41 cases, and see it cut in halves by the Westfield River,
near its junction with the Connecticut. We see Springfield
on the opposite bank of the principal river, with its smaller
proportion of 11 cases in 15,199 inhabitants ; Gran by, a little
further north, and about as far from the Connecticut as West-
field, showing 12 cases in 907 inhabitants ; Northampton, on
the west bank of the river, having 6 cases in 6,788 inhabitants.
Thence proceeding up the river, we find the towns which are
reported (several are not) having single cases till we come
to where the Deerfield river joins the Connecticut, much in
the same manner as the Westfield river makes its junction.
We observe that our reports show no such collection of cases
at this spot as at the point of union of the Westfield river
with the principal stream. We find at this point only four
cases — three in Greenfield and one in Montague. But, while
writing this paragraph, a long delayed " circular ;; comes in
from Montague with five additional cases in that town, and
containing the statement that the disease had prevailed as an
epidemic in the surrounding towns.* Many of the most

* The Circular arrived too late to be inserted in the tables, but it does not
materially affect their general results, except to strengthen the conclusions
already drawn, that the inland Counties have been more visited by the disease
than the Eastern. We shall give a report of the cases in a suitable place.

78 REPORT.

affected towns at a considerable distance from the Connecticut
are watered by its tributaries. Taking these things in con-
nection with the statements of Dr. Terry, as to the endemic
(as we have called it) in Sutton and Millbury, in 1849, that
the whole region over which it extended has "a soil very
retentive of moisture, and a damp atmosphere ; " while in
Millbury most of the cases occurred within a few rods of the
Blackstone River, which also skirts the town of Sutton ;
taking these things together, we have a prima facie case that
in exposure to moisture, or proximity to bodies of fresh water,
may be found one of the causes of the disease. But, let us
not jump at conclusions. We have to lament that we are
without full reports of the places where the disease was not,
as well as those where it teas. And a reliable induction
upon this point cannot be made without a thorough compari-
son of the two classes of places.

A good illustration of the difficulty attending an investiga-
tion of this subject occurs in the circumstances of the town
of Palmer. In that place, in which there were twenty cases,
three rivers meet, giving the name " Three Rivers " to one
of its villages. Here, then, we might be tempted to draw an
inference as to the connection of the disease with emanations
from the water. But, in -reply to inquiries from us, Dr. Hol-
brook, of Palmer, writes that the part of the town "most
afflicted with meningitis is very dry. The soil is of a sandy,
gravelly nature, and twenty-four hours after a long or hard
storm, the dust will fill the e3res." * * * "The Quaboag
River is not more than a quarter of a mile from our village —
an eighth of a mile would perhaps be nearer the distance.
But it is quite rapid — no stagnant water — no dams within
two miles of us." * * * There was, Dr. H. adds, one case in
Thorndike Village, one also in Three Rivers Village ; both
about three miles from the district where a large majority of
the cases occurred.

Of Westfield itself, also, Dr. George G. Tucker, of that
place, remarks, that there is in it "no standing water or
marshy ground — every thing in good sanitary condition —

CEREBKO-SPINAL MENINGITIS. 79

even ready for the cholera. The site of Westfielcl is, accord-
ing to geological suggestions, the bed of a former lake, six
miles long and three broad. Surrounded on all sides by
hills, except for a short distance on the south-east, where
this body of water was supposed to have its outlet, and
although its situation is low compared with its immediate
surroundings, it is not so as compared with the level of the sea ;
and the air is as dry as that of the most elevated tracts."

On the other hand, Dr. Tucker says, in another place, the
month of February, 185*7, in which the disease broke out in
Westfield, was exceeding mild, and the atmosphere for the
most part filled with vapor.

Portion of the State most affected not that of the greatest

" Rain-fall."

One thing it is easy to determine — that is, the region most
infested by the disease, so far as our reporters inform us, is
not that of the greatest "Rain-Fall," but of the second and
third degrees in the descending scale.

We here take leave of the geography of the disease, and
proceed to a brief notice of the

Dates of the Cases.

The first cases reported to us, are two in Becket, Berkshire
County, in April, 1851. Another case occurred in that town
in October of the same year. This was followed by five, be-
tween the 6th and 14th of March, 1858.

The disease broke out with violence in Westfield, Hamp-
den County, in January, 1858, and prevailed there again in
1859 ; also from 1861 to 1865. Instances have occurred in
this State, in each year, from 185*7 to 1866, inclusive, with
the exception of 1860, which is not mentioned in any of our
reports.

It needs but a cursory survey of the tables to show that the
disease, in this Commonwealth, did not follow, from year to

REPORT.

year, any regular course, relatively to the points of the compass,
but fell upon differeut spots, here and there, without apparent
order — sometimes retracing its steps.

The distribution of the cases in the State over the different
years of the epidemic is as follcfws, viz. :

In 1857 there were 3 cases.

27 "

3 "

0 "

5 "

7 "

88 "

116 "

It was also stated that " from 1864 to

1865 " there were 15 "

" from 1861 to 1865 " there were 8 "

The years were not mentioned as to 3 -"

1858

it (C

1859

(I (I

1860

a (t

1861

n u

1862

(( ((

1863

a a

1864

IC 11

1865

(t a

280

As we have, of course, no full accounts for
the present year, the cases in Brookline,
in January, 1866, are not to be counted
in. They amounted to 7

287

The months in which the cases occurred are given as fol-
lows, viz. :

January,

21 cases.

July,

8 cases.

February,

25 "

August,

4 "

March,

37 "

September,

4 "

April,

30 "

October,

5 "

May,

14 "

November,

2 "

June,

5 "

December,

8 "

163

cases

236

CEREBROSPINAL MENINGITIS. 81

January to April,
February to May,
February to April,
February to March,
March and April,
" Winter and Spring1/ '
February to July,
"July or August/'
November to December,

Not mentioned,

287 "

Now, if we take the first of the above lists — that in which
the number of cases is specified for each month separately —
we find that the number of cases set down to the first five
months of the year amounts in the aggregate to 127 ; while
those which occurred in the remaining seven months number
only 36. May has a much lower number than either of the
preceding four months.

In the second list, also, the cases representing exclusively
the first five months amount to 55 ; while those stated as
occurring in "July or August/7 and in November and
December, number only 6.

November and December, it will be noticed, though aver-
aging as great an amount of cold weather as any of the other
months, are among those with small representation of cases.

But, the months mentioned as giving the bulk of the cases
are those in which there is much alternate freezing and thaw-
ing ; and consequently much cold combined with moisture.

Meteorology.

As to the meteorology of the past nine years, which cover
the period of the present epidemic in this State, we are not
aware of any thing unusual to be recorded of it. On the
contrary there has been, as to the weather, the ordinary
diversity, from year to year, characteristic of this climate.
11

82 REPORT.

Sources of the Disease.

The sources to which the disease is ascribed by our corres-
pondents are —

Probable or possible contagion, in cases 16
Variously otherwise specified in the tables,

in cases T5

"Not known/' in cases 152

Not mentioned, " " 44

28T

Locality— High or Low, Damp or Dry.

The locality of the disease, as to level,

was not mentioned in 37 cases.

Not definitely stated in T "

Medium in 1 " 45

No preference for high or low was

shown in 143 "

The locality was high in 58 "

" " " low in 41 "

242 " 242

287

The dryness or dampness of the " locality " of

the disease was not mentioned in 52 cases,

leaving 235 cases.
Of these there was said to be no pre-
ference in 147 cases.
The locality was dry in 60 "
" " " damp in 28 "

235 " 235 "

287 "

CEREBROSPINAL MENINGITIS. 83

Occurrence of the Cases in Districts Thickly or Sparsely

SETTLED.

The term "thickly settled " varies its meaning so much
under different circumstances — particularly as between the
city and the country — that we have divided our cases under
the above caption into three divisions— the first composed of
those among the military on the Islands in Boston harbor,
numbering 23

The second embracing those in the City of Boston
(including South Boston), =43

The third, taking in all in the remainder of the State, =221

287
In Boston harbor there were 19 cases at Gallop's Island—
" over-crowded ; " 4 at Fort Warren, which went from Gal-
lop's Island, and were, while at Fort Warren, "as usual in
military quarters," i. e. crowded; in all 23

In Boston, there were, in a district " not very thickly
settled" (in South Boston), cases 3

(In City Hospital,) ditto, '• sparsely,"

" "medium,"
" "not crowded,"

"thickly,"
" "crowded,"

Settlement of district not mentioned,

5
1

16
1
1

In comparing these 43 cases inter se, we exclude those
whose localities are "not mentioned" (10); and also, as
bearing on neither side, the case (1) designated as occupying
a "medium" locality, together with 3 in a part of South
Boston "not very thickly settled " ; making in all, 14 ; and
leaving (of the 43) 29 to be reckoned upon. Of these 29,
their locality is given as

" Sparsely " settled in 5

" Not crowded," i. e., the better class of city streets, 1 6

84 REPORT.

Against these 21 cases we set off, as in " thickly " settled
districts, 1, " crowded, " 1=8. This gives us between two
and three times as many cases in the less thickly settled parts
of the City of Boston, as there were in the thickly settled or
crowded portions (21 to 8).

On the main land outside of Suffolk County, the cases are
221 in number, and are classified as follows, viz. :
Cases in which settlement of locality is not men-
tioned, 10
Cases indefinitely described, 1
Do. " medium, " 6

Case in " Dorch sster," 1 18

Excluding the above 18, we have left 203 ; of these
there was as to locality "no preference" in
cases 99

There were in places " thickly " settled, 26

" " " " rather thickly settled for

country town/' 3

" " " "sparsely" settled, 74

" " a "village," 1—203

221

Of the above 203 cases, 99, or nearly one-half, showed "nc
preference" in their choice of locality whether "thickly" oi
"sparsely" settled. Of the remaining 104 cases, 26 were
in places set down as "thickly" settled; and 3 in a place
"rather thickly settled for a country town," =29 cases
Against these we set off 14 cases in a " sparsely " settled
region, and 1 in a "village " =75.

Thus we have between two and three times as many cases
in the " sparsely " settled as in the " thickly " settled locali-
ties. This result tallies closely with that in Boston.

Now taking our three divisions of the State together, we
have in Boston harbor,

In " over-crowded " barracks, cases 19

In ordinary military quarters, " 4 — 23

CEREBROSPINAL MENINGITIS. 85

In thickly settled quarters of Boston (no

other towns of Suffolk Co. being affected) " 8

On the main-land, outside of Suffolk Co., in

more or less thickly settled localities, 29

In the less thickly settled parts of Boston, " 21

In the less thickly settled regions of the

remainder of the State, " 15—96

We thus get a majority of 36, out of 96 cases throughout
the State, in favor of the less thickly settled regions.

To confront the question of the distribution of the cases
from another point of view — that is, as between the Metro-
polis and the rest of the State- — we have only to repeat, what
we have already deduced from previous statistics, that there
is not a material difference between the proportion of cases
to population in Suffolk County, and the proportion of cases
to population in the remainder of the Commonwealth.

These facts bear, as will be hereafter seen, upon the pa-
thology of the disease.

Condition of Patients.

In asking the questions, " How many were in easy or com-
fortable circumstances?" and "How many were poor?'7
we include in the former category all who were not subjected
to privation. These questions were not answered as to

cases 34

Leaving 253.

There were in the xUmshouse at Monson, " 2

At the Boston City Hospital, " 5

Soldiers in Barracks, " 23

In easy or comfortable circumstances, " 89

Poor, " 26

There was "no preference" in " 108 — 253

287
In recording the ages of the cases, we have, acting by ad-
vice, made an arbitrary division of them ; as follows, viz. :—

86 EEPOET.

Under 15 years, we call " Infancy or Childhood ; " from 15 to
20, " Adolescence ; " from 20 to 50 "Middle age;" from
50 upwards, " Advanced age."

Ages.

In taking account of the ages, we exclude

cases in which the age is not mentioned, 4

Also cases in which the age is not definitely

mentioned, 5

Cases stated to be " about half of them

children and half adults,'7 18

* Soldiers of middle age, 9

" in adolescence 14 50

This leaves us 237 cases, out of which we
have, as explicitly reported.

In " Infancy or Childhood," 79

In Adolescence, 12

Adults, 67— 158

showing a preponderance of 24 cases in the
two earlier periods of life over those of
adult life. This preponderance is strength-
ened by the following statement, viz. : —
There were "chiefly children" incases 44

Of a group consisting of children and youths
there were " chiefly children." The
group consisted of 4

There were "young lads mostly" in cases 16—64

There were chiefly " adults " in " 15—237

287

It remains to say that of the adults number-
ing (still exclusive of the soldiers) 67,
The exact age was not mentioned in cases 17

The age was " advanced "in "4

The patients were of " middle age "in " 38

* Soldiers are excluded as Tbeing of selected age.

CEREBROSPINAL MENINGITIS.

The subjects were chiefly of ' middle age7' in cases 8 — 67

Among the " greatest ages" we find one subject to have
been of 72 years — another of 65 years ; among the earliest
ages, two of four months each, and one of five months. No
period of life was exempt.

Sex.

The sex was not mentioned in cases 29

The subjects were soldiers in barracks in "23

We therefore exclude "cases

■

The male sex was represented in
" female " " "

This gives us a preponderance of nearly 60

per centum of males over females.
This preponderance is increased by a group

of 16 cases " mostly lads/7

52
131

287

"Sporadic or Epidemic.

There was no entry under this heading in cases 32

The replies were " doubtful 77 in " 13 45

The term " Sporadic 77 was applied to " 131

" " "Epidemic77 " " " " 111—242

287

Although the larger number of the cases competent to be
reckoned upon were considered by their reporters as sporadic,
we presume the whole 287, taken together as for the State,
may be regarded as constituting an epidemic.

Contagion.

The question "were there evidences of conta-
gion ? 77 was not answered in cases 19
leaving 268 cases to be reckoned.

88 REPORT.

It was answered affirmatively three times,

i. e., by one reporter as to cases 5

by another as to "1

by a third as to " 4 — 10

There were coincidences pointing to contagion

in three other reports, together comprising
cases numbering 6

Thus out of 268 cases in which the point was

mentioned, the answers were negative as to 252 — 268

281

In relation to the 16 cases above-mentioned as more or
less suggestive of contagion, we proceed to show the evidence.

Two of the " doubtful " cases are in the report of Dr. Page
concerning the epidemic at Gallop's Island. One of them
was that of a physician who attended a case of " Spotted
Fever" previously to going to the Island. The other was
that of a recruit who occupied the bed previously used by
another patient who had had the disease. No comments
were made by Dr. Page upon these facts ; and we give the
evidence as it stands.

Dr. Seaverns answers affirmatively to the question of con-
tagion as to the 4 cases at Fort Warren ; saying they "all
occurred in the same barrack, and all came from a place
[Gallop's Island] where there had been cases previously."

In 2 cases the reporter of them gives it as his opinion that
the disease was contagious from what he had seen of it pre-
viously, but does not appear in his letter to show evidence
for it in these particular cases.

In two other cases the reporter answers negatively to the
question whether or not there were evidences of contagion,
but adds, "it would seem as though the children took it [the
disease] from the father, or the same cause operated to pro-
duce it in all three."

In six cases in Northampton, Dr. Thompson thinks five
were all " causatively connected by contagion " with the
first case — a stranger who imported the disease. There were,
he says, " six cases in two families — locations apart and dif-

CEREBROSPINAL MENINGITIS. 89

ferent. The first patient in the second house had had con-
tact with the first in the other (i. e., the stranger woman)
at a manufactory, away from either dwelling. In one of the
houses three families lived separately. Three cases in one of
the three families — no one else sick under that roof."

The remaining case answered in the affirmative was one
where the patient — a physician — had visited a case of the
same affection two weeks previously. (Vide cases of Dr.
David Eice.)

We have presented the evidence as to these cases of con-
tagion alleged or suggested. The writer, speaking for him-
self alone, sees in most of them, coincidences, but is not sat-
isfied that the "causative connection77 is proved in any of
them. The four cases in soldiers who went from Gallop7 s
Island to Fort Warren, we would submit, may have gone
with the seeds of the disease in them. And it is to be noted
that they did not communicate it to others in the garrison.

Duration.

As to the duration of the disease our tables give us com-
paratively few cases in which it is specified for each case ;
and so great is the diversity in the length of the cases (taking
the deaths with the recoveries) that a general average would
throw little light on the behavior of the disease in this respect.
We have, however, drawn off the durations of the single
fatal cases, and single cases of recovery ; and also, the
" average durations 7; of the groups of cases which were all
fatal ; and, separately, those of the groups which all termi-
nated in recovery, as follows, viz. : —

REPORT.

Average duration.

Less than 3 days
5 days

about

36 hours

4 days
25 hours
39 hours
31 hours
18 days

2 days
6 weeks
3h days
36 hours

5 days
10 days

Fatal Cases — Duration.

Cases. Average duration. Cases.

8 12 months

1 24 hours

1 12 days
7 4 days

2 42 hours
5 3 days

1 48 hours
4 3 days

2 13 days
1 2i days

1 Less than 24 hours

2 about 1 week
2 5 days
2 4 weeks

— 43 hours

39 4 days

10 days
4 days

22-

Average duration. Cases.

2h months ") ,

Relapse? >

4 days 1

23 days 1

4 weeks 2

30 hours 1

36 hours 1

14 days 1

23 days 1

11 days 4

a few hours 2

22
39

Fatal cases at Gallop's Island, deduced from pub-

ished report.

Duration. Cases. Duration. Cast

5 days ]

L 2 days 1

2 days ;

I 19 days 1

2 days ]

8 days 1

30 minutes ]

L 18 days 1

1 day ]

2 days 1

2 days !

12 hours 1

14 hours 1

4 days 1

1 day 3

3 days 1

8 =16

Additional fatal cases obtained from inspection of
the Circulars, and not distinguishable in the tables.

30 days, 1 case

" a few hours/' 1 case

4 days, 1 case

Fatal cases, total =95

CEREBEO-SPINAL MENINGITIS. 91

We have, in the above lists, 66 cases in which the result
was fatal, and in which the duration, or the average duration,
was 5 days or under; 1 fatal case of 8 days duration ; and
28 fatal cases, the duration, or the average duration of which,
was 10 days or over.

Of the " 12 months77 fatal case in the preceding list (Dr.
Faulkner's), the reporter says — "the patient died in one
year, after months of activity, but not of recovery.77 This is
the longest fatal case we have as yet met with. Our list also
contains the shortest case we have seen on record, whether
among fatal cases, or recoveries — 30 minutes from the acute
attack. The patient, however, had vomited, a few hours
previously, from, as it was supposed, an overloaded stomach.

Cases of Recovery — Duration.

Average duration. Cases. Average duration. Cases.

3 weeks 4 10 days 4

2 weeks 1 54 days 1

3 weeks 6 T weeks 1
2 weeks 1 " Say 77 4 weeks 4

4 weeks 2 " Many months 77 1

31 days 1

8 hours 1 4J months 1

45 days 1 5 months 1

2 months 3 8 weeks 1
8 weeks to conva- ) —

lescence, 1 year to >- 1 15

full health ) 3 weeks-j- 1 ) From

About 1 weeks 2 11 weeks+ 1 1 Gallop's

— 26 days-}- 1 } Island.

22 —

18
Additional cases of recovery obtained from inspection of
the Circulars, and not distinguishable in the tables.

Average duration. Cases. Average duration. Cases.

1 week 1 3 weeks, acute stage,

3 weeks 1 recovery protract-

ed further,

2-}-3=5 cases.

92 REPORT.

Duration discriminated in

Cases of recovery 22-f-18-J-5= Total, 45

Fatal cases (bro't over from p. 90) " 95

Cases in which the duration was not discriminated) -..«
for fatal cases and those of recovery, j

287

The eight hours case in the list of recoveries was 8 hours
under the acute attach ; after which, we are told, the conva-
lescence was rapid. It was interesting as having been treat-
ed after the manner of sun-stroke in India ; and in being as
exceptional in its brevity for a case of recovery, as the twelve
months fatal case was for its length.

In the vast majority of the cases of recovery given above,
the duration of them may be stated in weeks and months ;
while in a large majority, more than 2 to 1, of the fatal cases,
the duration was of days or hours.

In some of the statements the average duration was given
as approximative ; but, in all, we presume with sufficient
accuracy for practical purposes.

Kelapses. .

Besides the case of relapse of Dr. Faulkner, fatal at the
end of a year, there were among the cases of Dr. Holland, of
Westfield, 5 relapses, three of which were fatal. There were
relapses also in both the cases, fatal, of Dr. Cabot, of Boston ;
in three (which recovered) of Dr. Borland's cases at the
City Hospital in Boston ; in some or all of the cases of Dr.
Seaverns, at Fort Warren, all of which were fatal.

Since no question was put, in the circulars, as to relapses,
that event may have occurred in others of the cases in the
tables without our being cognizant of it.

CEREBROSPINAL MENINGITIS. 93

Convulsions

were not mentioned in cases 36

leaving 251 cases to be accounted for.
Of these the symptom was absent in cases 123

" " " " was not frequent in cases ?

130

It was present in " 72

There was much convulsive action in " 4

" Spasmodic action " was frequent in " 16

Convulsions were "a frequent occurrence" " 18

There were ditto in "most" of a group of " 9

" " cramps in the arms and hands in " 1

Hands clenched in " 1 — 251

287

We may estimate that convulsive action, in one form or
another, was present in considerably less than half the cases
in which the symptom was mentioned.

Headache

was not mentioned, or ]

was not ascertained — as where patients were j

unconscious, \ in cases 25

" as where patients were j

too young, j

This leaves 262 cases to be accounted for.

Of these it was present in cases 191

" " " " "frequent" " " 16

It was present " in every case in which
the sufferer could describe his sensa-
tions," in groups consisting of " 24

Present "in all fully developed cases,"

of a group of 19

250
It was absent in cases 3

94 REPORT.

" Several complained of severe headache, others
but little/7 in a group composed of cases 9 — 262

287

Thus, we may say headache was present in a vast majority
of the cases in which the symptom was mentioned, or its
presence or absence could be ascertained. In the three cases
in which it was stated that it was absent, we are left in the
dark as to the circumstances — whether, for instance, the pa-
tient were conscious or not. In no fully developed case are
we distinctly told that the patient was conscious of sensation,
and yet free from pain in the head.

When the degree of the headache is mentioned, it is some-
times said to be mild ; more often severe ; by one observer,
" terrible ;" by another, " excruciating. "

In 19 cases the part of the head affected was mentioned.
In 10 the pain was in the back part of the head ; in 3, in the
"back part especially.7' In 6 cases the pain was in the
front part.

In 7 cases it was mentioned that pain extended from the
head, more or less down the spine. Of 17 other cases, this
occurred in every one where the sufferer could speak. The
record does not show that this extension did not take place
in other instances.

Delirium

was not mentioned in
" perhaps masked by coma in
The patients were unconscious in

" " too young to manifest it in

This leaves 264 to be accounted for.
The symptom was present in cases 165

" present in "nearly all" of " 24
" " generally present in " 16

cases

CEREBKO-SPINAL MENINGITIS. 95

The symptom was present in "' nearly all not

relieved in 24 hours " in " 14

Present "in all the fully developed cases "

in a group of "18

237

Delirium was absent in

" 26

" " not marked in

1—264

287
Thus, in a very large majority of the 264 cases to be reck-
oned upon, delirium was present. The character of the de-
lirium was variously described as — mild ; violent ; low mut-
tering, &c.

Of 165 cases in which it was stated, without qualification,
that delirium was present, the question as to logical answers
was not mentioned in cases 23

Logical answers were given in cases 104

" " " "generally" given in " 17

" not given in " 21—142

165

It results, therefore, that in a very large majority of the
cases, 165 in number, in all of which it was stated that de-
lirium was present, and in which our reporters replied to the
question as to logical answers, the delirious could be roused
to give such answers.

Also, of the cases which will be found numbering 72 on
pages 94 and 95, in which delirium was said to be more or
less generally present, the delirious could, in a majority, be
roused to give logical answers.

Opisthotonos

was not mentioned in cases- 23

Replaced by emprosthotonos in " 1

Doubtful in " 2

EEPOET.

leaving 261 cases to be accounted for.
There was severe opisthotonos in cases 107

" slight " in " 80

187

There was opisthotonos "in nearly all" of

a group of cases amounting to 9

There was opisthotonos " in about two-
thirds" of a group of cases numbering IT

Absent in cases

Tenderness at Nucha

was not mentioned, not observed, or not

recorded, in
was not ascertainable in
The patients were unconscious in

213

48—261

287

cases 75
" 1
" 3

leaving 208 cases to be accounted for.
The symptom was present in

do. " in nearly all " of

"Probably in all" of

There was great soreness and stiffness in
In all who could describe in
Replaced by pain on motion in

" " " between shoulders in

" "pain"
Absent
"Not marked"

cases 121

" 15

155
1

7
2
1
2
33
7—208

287

It may be estimated that tenderness at nucha was present
in about three-fourths — or at least in more than two-thirds — ■

CEREBBO-SPINAL MENINGITIS. 97

of the 208 cases competent to be reckoned upon. Perhaps
if attention had been drawn to the symptom we should have
had reason to rate it as still more frequent.

Pulmonary or Pleural Symptoms.

Among these we include, those slight and severe, sympa-
thetic or otherwise. (Vide tables.)

They were not mentioned, or not observed, in cases 71
leaving 216 cases to be accounted for.

PreseDt in cases 59

" " "most" of a group of " 17

Hurried respiration "generally" pre-
sent in a group of " * 9

Respiration abnormal in about half of a

group of "19

Above symptoms present "in some"

of a group of "16

Above symptoms " not mentioned " of

a group of "7

Above symptoms absent " 89 — 216

287

N. B. — Among the so-called pulmonary symptoms, difficult
respiration, as simply a functional disturbance, figures
largely. (See tables.)

Abnormal Conditions of the Heart, including those of the

Pulse.

For descriptions of the above, we refer to the tables. The
figures below relate almost entirely to the pulse.

Abnormal conditions are set down by us as indefinitely

described, not recorded, or not mentioned, in cases 50
This leaves 237 cases to be accounted for.
Abnormal conditions were present in cases 174

" " were generally present in " 19

98 REPORT.

The pulse was generally frequent in cases *7

" " " variously affected in " 18

No " well-marked " abnormal condition of

heart or pulse in "16

The pulse was " not ■particularly quick " in " 2

" " " "not much disturbed" in ce 1

287

It may be seen, by inspection of the tables, that there was no
one departure from the normal standard of the pulse generally
characteristic of the cases. It was occasionally retarded ;
sometimes variable ; often accelerated. In some instances,
again, it was not much affected.

Abdominal Symptoms.

As it does not clearly appear in most of the circulars
whether abdominal symptoms, when not recorded, were ab-
sent or mention of them omitted (owing to a misprint in
the circulars), we give no summary of results ; but refer to
the tables for descriptions of such as are alluded to. Nausea
and vomiting are not unfrequently spoken of.

Abdominal symptoms have generally no prominent place,
either in the accounts which have come down to us of the
epidemic of 1806 to '15, or in the published reports of later
visitations of the disease.

Petechia or other Morbid Appearances of the Skin.

The descriptions we have received of the above are given
n a condensed form in the tables.
Morbid appearances of the skin were not mentioned

in cases 29

Were not looked for in " *l

Were not recorded in (hospital cases) " 2

leaving 249 cases to be accounted for.

CEREBRO-SPINAL MENINGITIS. 99

They were present in

They were very general in

Peculiar condition of the skin, in some cases

without spots, of a group* of
They were " not marked " in
They were not present in

cases

129

< t

249

287
We may say, then, that petechias, or analogous spots, were
present to a marked degree, in somewhat less than 59 per
centum — of 249 cases competent to be reckoned upon. Tt
is easy to see, on inspection of the tables, that petechias and
opisthotonos were often combined in the same individual.

The Termination

was not stated in cases 9

leaving 278 cases to be accounted for.
The termination was fatal in cases 170

Recovery took place in " 108

■ 278

287

The percentage of fatal cases in the 278 cases to be reckon-
ed upon was a little over 61. The percentage of recoveries
was a little less than 39.

AUTOPSIES, TREATMENT, REMARKS.

Where there has not been room for either of the above in
the tables, we give them here, designating the cases to which
they belong by numbers corresponding with those under
one or more of the above captions in the tables. ■

* Vide tables. Cases of Dr. Orcutt, Worcester Co.

100 REPORT.

I. Dr. E. G-. Wheeler, Becket. No autopsies.
Treatment. In two cases Dr. W. took blood freely from

the arm in the commencement, and in all cases followed up
the antiphlogistic plan, whenever arterial action seemed to
call for, or even allow of it ; aided by counter-irritants along
the course of the spine. For internal remedies he depended
chiefly upon sulph. quinine and opium, and generally gave
them in combination.

Remarks. In one patient, »t. 45 years, Irish, a respecta-
ble laborer, the symptoms yielded very readily to prompt
antiphlogistic treatment — venesection, cupping and coun-
ter-irritants over the spinal cord, and internally quinine and
opium. Subsequently, on the second day from the attack,
he was able to sit up, and when left alone went down stairs,
and some four or six rods to the spring through thawing
snow, having only thin shoes on. Immediately upon his
return to his chamber, he was taken with a severe chill ;
skin became cold and blue, no reaction came on, and he died
in a few hours. * * *

II. Dr. William W. Greene, Pittsfield.

Autopsies in three Brain much engorged. Base

and spinal cord covered with a yellowish green, illy organ-
ized exudation, which sometimes lined the ventricles, and
covered posterior part of cerebellum.

Treatment. Cathartics, anodynes to relieve pain, large
doses of quinine and stimulants, decided counter-irritation
at nucha. In one, venesection.

Remarks. The exudation resembled very much that of diph-
theria. One man was violently attacked with cerebrospinal
symptoms and abundant spots, lasting for two days, when an
abundant exudation occurred in the throat, and all the pain,
delirium, opisthotonos, tenderness, &c. disappeared.

III. Dr.. David Rice, Leverett, &c.

Treatment. Blisters the sheet anchor, applied succes-
sively to the spine nearly its whole length ; mild cathartics ;

CEREBROSPINAL MENINGITIS. 101

during convalescence, stimulants and tonics; frictions with
tincture of cayenne and alcohol; mild anodynes ; cupping.

1 V. Dr. D. Bradford, Montague.

VV UmerU. Anodynes, stimulants, and aperients. Sudo-
rifics at first, with bottles ^i' hoi water externally and sina-
pisms. Opium and Btimulante were given freely on last days
of Bicki — .

v. Dr. 0. Temple, Beath, &c.

opium in the early stages ; Later, quinine, or
protoxide of iron with Peruvian bark.

/,'• The patient, aged 1 1 years, w ho was sick sixty

lid uot Bpeak or move a Limb, except the Left foot, at
any time from the 6th to the 36th day. then gradually
■ed,

V I. Dr. Jam land, Westfield.

J Morbid appearances were confined to the

membranes at the b the brain and in spinal column.

• c of dura mater was darker. Patches of coagulablo
lymph of greenish color were found scattered between the
arachnoid and pia mater at base of brain. Spinal cord in-
npletely by thin lymph. Turbid serum was found
in every c e, pus and small (dots of blood.

if two of the Lumbar vertebras, at the point of exit
of the spinal nerves, was found in one ease. Paralysis of
the Lower Limbs attended this case for five weeks previous to
death. Induration of the spinal cord was found in every case.
f the medullary Bubstance of the brain or cord
was not discovi red in any < • -<• the one in which caries

of the lumbar vertebrae existed, and that only at the point
where the bone was diseased. At this point pus was found,
a portion of which had passed out along with the spinal
nerves into the adjacent muscles.

7 V- No mode of treatment adopted was satisfac-

tory. The application of large numbers of leeches to the

102 REPORT.

occiput and neck, keeping up the bleeding for a length of
time bv means of warm fomentations, gave relief for one or
more days in every case where made. Cupping did not an-
swer as well as leeching. Strong mustard poultices, fre-
quently renewed^ to the whole length of spine, gave great
relief to pain. Blistering largely with emp. lyttee also
afforded the same temporary relief. Calomel purges in the
very first stage, were in every case administered, and small
doses repeated several times daily until the gums were
touched, without permanent benefit. Opium in various
forms, hvoscvamus and belladonna were Q-iven with good
effect in allaying pain — but never in large doses. Fluid ext.
veratrum viride, in doses from three to five drops, afforded
marked relief, abating the throbbing pain in every case
in which it was 2,'iven. It was 2,'iven everv two or three
hours during the paroxysms of pain, which usually returned
in the night time. As an arterial sedative, it far excelled
every other remedy I used in treatment of this disease.

Be/narks. Rigid contraction of the muscles of the spine
was a marked feature in every case in 1S5S — especially was
this noticed in the muscles of the neck in every case. Two
children, one eleven and the other thirty months old, were
unable to swallow anything for a period of about eight days
previous to their death, so violently and rigidly were their
heads drawn back. They died on the eleventh day of the
disease.

VII. Dr. W. AT. Trott, "Williamsburg.

Remarks. There was soreness of the throat, slight. There
was nothing to indicate immediate death till a few moments
before the patient expired.

Till. Dr. A. "W. Thompson", Northampton.
Treatment. Supporting and stimulating, with various de-
vices from day to day, according to the indications.

CEREBROSPINAL MENINGITIS. 103

Remarks. In one case the tenderness at nucha, which was
marked, was followed by utter loss of power of the muscles
which move the neck.

IX. Dr. L. E. Marsh, Granby, &c.

Treatment. Antiphlogistic and sedative at the commence-
ment— afterwards stimulant and tonic.

Remarks. In several cases congestion of the lungs com-
plicated the disease. In three of the cases paralysis super-
vened, and those proved fatal. In one case pleuero-pneumo-
nia set in and carried off the patient, a woman of 45.

Dr. M. considers the disease of the same nature as diph-
theria. In one case — a girl of 15 — there was complication
with diphtheria. The patient recovered and was well the
August following her attack (which was in March), except-
ing in point of strength.

X. Dr. J. W. Gooddell, Greenwich.

Treatment. Tonics, stimulants, and nourishment " of the
strongest kind ; " also powerful counter-irritants the whole
length of the spine, particularly at nucha. Blisters, iodine,
chloroform, ammonia, cupping, &c. &c. To one boy, 13 years
old, Dr. G. gave almost & pint of whiskey in two hours, with
no perceptible effect.

Remarks. The " locality " was a sandy plain, with a
pond one mile distant, both east and west. Beyond are the hills
of Hardwick on the east, and those of Prescott on the west.

In the month following these cases, says Dr. Gooddell,
" we had some 30 cases of severe typhoid pneumonia — many
commencing with all the symptoms of meningitis." Some
of these cases were left in a very prostrate condition ; one
was followed by paralysis of right arm. All of them reco-
vered except two, who were over seventy-five years of age.

XI. Dr. George G. Tucker, Westfield.

Autopsies. Dr. T. made 8 autopsies. He found the cere-
bral substance not morbidly affected. Patches of lymph

104 REPORT.

were almost always seen distributed over the surface of the
pia mater with some opacity of the membrane ; and also
collections of fluid lymph of variable quantity, extending
sometimes the whole length of the spinal cord and complete-
ly surrounding it. The cord itself was very perceptibly
changed in many cases — softening in different degrees — some
sections being of about the consistence of cream. Mem-
branes somewhat injected.

The treatment consisted in powerful counter-irritants applied
over the spine — sinapisms, blisters, setons and the actual
cautery ; an efficient cathartic at the commencement, with
alteratives in the form of mercurial preparations, and per-
manganate of potash. Opium was always used freely when
the brain tolerated it. Inhalations of sulphuric ether were
frequently given, with much temporary relief. In the more
prolonged cases, assuming an adynamic condition — iron, qui-
nine, strychnine, electricity, alcoholic stimulants. Some
cases put on a ''typhous" aspect at the commencement,
which required general treatment of a tonic and stimulating
character.

Bemarks. The mode of invasion varied considerably in dif-
ferent cases. In some there were the usual symptoms of febrile
disturbance : chills, rigors, pain in limbs, head, &c, with occa-
sional vomiting, diarrhoea, or cosliveness ; the neck gradually
becoming stijf, followed by opisthotonos more or less complete.
* * * In other cases there were no formative periods or
premonitory symptoms, the patient being suddenly insensible and
convulsed, ivith the rapid formation of opisthotonos, which in
live or six cases was very perfect. * * * The character
of the delirium varied in some respects. In the cases at-
tacked suddenly it was impossible to arouse them, or arrest
attention in the slightest degree. In cases not suddenly at-
tacked, the patient would at times fix the mind upon ques-
tions asked, long enough to give intelligent answers. Some
degree of bronchial irritation and pulmonary congestion
were present in some cases, though never sufficient to be
a complication of much importance. * * *

CEREBRO-SPINAL MENINGITIS. 105

XII. Dr. J. Abbott, Westfield.

Says the remedies which seemed to do the most good were
Bryonin and Rhus toxicodendron — the strong tinctures.

XIII. Dr. William G. Breck, Springfield, &c.
Autopsies showed, in cases in which death occurred early,

inflammation of membranes of brain and spine ; in those
which died later there were purulent deposits. There were,
however, traces of pus in some rapid cases.

The treatment was by counter-irritants of the most active
character. Sedatives, alteratives, and in some cases opiates,
acted well. In some cases, also, large doses of hydrargyri
submurias seemed to have good effect. Oil of turpentine
and veratrum viride were given.

Remarks. The cases that did the best were those in which
the occiput and the whole spine were early vesicated — calo-
mel in large doses being given early.

XIV. Dr. M. Calkins, Springfield.

Treatment. Tr. aconite, cold water to the back of the head
and the spine, hot pecliluvia, copious draughts of tepid water.

XV. Dr. William Holbrook, Palmer, &c.

Treatment. A variety of treatment was tried : stimu-
lants, tonics, cupping, blistering, &c. &c. ; opium, calomel,
veratrum viride, &c. &c.

XVI. Dr. Samuel Shaw.

Treatment. Aconite and belladonna — applications of cold
water to the affected part. In the first case he saw, Dr. S.
applied mustard paste, but found it to aggravate the diffi-
culty. He then adopted cold water as an application, with
better results.

XVII. Dr. J. P. Lynde, Athol.

Autopsy. Dr. L. examined the spinal cord in one case, and
found it coated over with a thick, greyish white albuminous,
14

106 EEPORT.

or, some would say, fibrinous exudation, slightly adherent
to the membranes. Brain not allowed to be examined.

XVIII. Dr. F. A. Wood, Petersham.

Treatment. In 3 cases which died, Dr. W. gave whiskey,
anodynes, and tonics. In one which recovered, he purged
with calomel, blistered the base of the skull, and cupped
the temples till faintness took place.

XIX. Dr. A. A. Orcutt, Hardwick, &c.

Treatment. Hot baths, and cloths wet with very hot wa-
ter to the nucha ; tonics and stimulants.

XX. Dr. S. P. Martin, New Braintree, &c.

Treatment. Warm baths, hot applications to spine, coun-
ter-irritants, cupping, occasional cathartics, anodynes, tonics,
stimulants.

XXI. Dr. E. M. Wheeler, Spencer.

Treatment. The first case got a brisk emetic and a cathar-
tic. The other had spontaneous vomiting and diarrhoea.
They both received anodynes, morphine and chloroform, hot
stupes of dilute alcohol, occasional laxatives — followed by
tonics.

Remarks. In the last case mustard was attempted to be
applied to the spine previously to Dr. W.7s arrival, but was
followed by appearances of approaching convulsions, and
was removed. Botli patients had numbness of the arms
and legs ; and one had ostitis of one knee, which lasted some
months.

XXII. Dr. J. T. Rood, Brookfield.

Treatment. About twenty minutes after the patient first
complained of being ill, she had a convulsion. Soon after
this Dr. R. saw her and found no perceptible pulse. He gave
whiskey very freely, and as soon as the pulse rallied, immers-
ed her in a warm bath ; then stimulated freely again, and
put a strong sinapism about six inches wide the whole length

CEREBROSPINAL MENINGITIS. 107

of the spine — applied heat to the feet and cold to the head.
In ten hours from first attack the patient went to sleep, and
from that time her convalescence was rapid. This is the case
alluded to before as one of sudden invasion, treated after
the manner of sunstroke in India.

XXIII. Dr. G. D. Colony, Fitchburg, &c.

Autopsy. There was no post-mortem in either of Dr. C.?s
cases. But he mentions that at the autopsy of a patient of
a neighboring physician in Westminster, the surface of the
brain and the spinal cord, " beneath the arachnoid and invest-
ment," was covered with a yellowish half-organized deposit,
quite abundant in many places.

XXIV. Dr. Benjamin F. Heywood, Worcester.
Treatment. Dry cups to back and sides of neck, sina-
pisms, opiates, diffusible stimulants.

XXV. Dr. 0. Martin, Worcester, &c.

Treatment. Free purgation to begin with. Blisters to
neck and spine. Opiates to procure sleep. After a few
days, stimulants and nutriments. The bowels were kept
open without purging.

Remarks. Dr. M. says one of the cases was left very fee-
ble, also deaf. He was subsequently drowned in less than
four feet of water — falling, as was supposed, in a convulsion
generated from the old disease.

XXVI. Dr. C. C. Field, Leominster.

Treatment. Alteratives and laxatives, blisters, low diet.

XXVII. Dr. C. A. Wilcox, Upton.

Treatment. Calomel, opium and camphor, cathartics, fric-
tions, with stimulating agents along the spine.

XXVIII. Dr. C. W. Barnes, Marlboro'.

Remarks. In the case showing no convulsions, there was
constant jactitation. No. 1 was attacked soon after recovery

108 REPORT.

from scarlet fever ; No. 2, immediately after coasting on a
very cold night.

XXIX. Dr. F. Buxdy, Billerica.

Treatment. The first case did not recover " from the con-
gestive stage." Stimulants and mustard were used freely.
In the second case, morphia to control pain, cold to the head ;
also showering, beef tea, veratrum viride, cathartics and
injections.

XXX. Dr. C. Jordan, South Reading.

Treatment. In two, depletion with counter-irritation to
the spinal colamn and extremities. Both fatal. Third case,
counter-irritation and tr. ferri murias. Recovered.

XXXI. Dr. J. Allex, Boxford, kc.

Treatment, Permanganate of potassa was given to the
child that recovered. Was attended with a copious secretion
of urine.

XXXII. Dr. S. Salisbury, Brookline.

Treatment. In the older patients cathartics at first, then
antispasmodics : in the younger, expectant treatment.

Remarks. In the recoveries, convalescence was very slow.
All the patients slept in apartments small, in proportion to
the number of occupants, and made as close as possible.

XXXIII. Dr. J. S. Greexe, Dorchester.

Treatment. A cathartic at the outset, enemata subse-
quently ; opiates ; aconite or veratrum viride pro re nata ;
permanganate of potash ; quinine in early convalescence,
turpentine later : whiskey was not well borne. Beef juice
was given freely during the acute stage. Cold to the head
was used, and counter-irritation assiduously.

XXXIY. Dr. C. E. Ware, Boston.

Treatment. Supporting, with moderate doses of quinine,
was the course with all the successful cases. Dr. W. lost

CEREBROSPINAL MENINGITIS. 109

none after he followed it persistently. He thought a very
free use of stimulants, especially early, decidedly mischievous.
Remarks. In several of these cases diphtheria unequivocally
existed. In one family where there were four cases, unques-
tionably all of the same disease, the petechial eruption and the
diphtheritic condition of the throat existed in some, but not in
all.

XXXV. Dr. L. R. Sheldon, Boston.

Treatment. Ice to the head and back of the neck ; vera-
trum viride ; frequent sponging of the surface. Dr. S. has
used a mixture of belladonna, nitric and chloric ether freely,
and opiates occasionally.

XXXVI. Anonymous, Boston.

Remarks. The case occurred on the last of three consecu-
tive days of the most intensely cold weather of the season.
[Contrast this fact with the warm damp weather which mark-
ed the commencement of the disease at Westfield, in 185*7.
See page 79.]

There were chills at first, followed by general pains and
vomiting. The child ate her breakfast as usual, and went to
school apparently in good health. She was seized while in
school, and died in less than forty-eight hours.

XXXVII. Dr. A. A. Gould, Boston.

Treatment. The jaws were so rigid that no internal reme-
dies were effectually used after first day. Cold to head and
back of neck — heat to the feet — frictions and stimulants to
surface.

Remarks. The patient was five months pregnant — aborted
on second day — no relief to rigidity, and no return of con-
sciousness afterwards — except there was always moaning
expressive of pain on any attempt to turn the head or move
the body.

110 REPORT.

XXXVIII. Dr. J. F. Gould, South Boston.
Treatment. Ice to the spine — laxatives — broth. Owing to

an abscess of the throat, one patient could not swallow food
or nourishment, except for about twenty hours of the first part
of the disease. This case was fatal.

XXXIX. Hospital case under care of Dr. J. B. S. Jackson.
Treatment. Leeches to the renal region. Pulv. Dov. —

Hoffman's Anodyne — the first three days took R Pulv. opii
gr. J ; Antim. tart. gr. -J- ; Hyd. submur. gr. j. ; ter die. —
After that, symptoms were treated as they came on.

Bemarks. "This case has been marked as cerebro-spinal
meningitis, as it is believed to have been a case of the disease
described under that name ; not that I think there was any
proper inflammation of the membranes/' Signed,

"Jackson."

XL. Hospital case under the care of Dr. A. A. Gould.

Autopsy. Head. The pia mater at the base of the cere-
bellum, around the medulla oblongata, in two very limited
portions near the vertex, and in one posterior lobe, was in-
filtrated with thick pus. The ventricle contained about §iij.
of turbid serum. The substance of the brain appeared normal.
Spinal Cord. The spinal cord was so much swollen in the
cervical portion as to fill the canal. The pia mater through-
out was opaque, and more or less infiltrated with pus.
While contained within the membranes, the cord felt very
firm, and was much stiffened, but on incision it proved to be
decidedly softened.

XLI. Cases at City Hospital in Boston, reported by Dr.
J. N. Borland.

Treatment. In the cases that recovered ergot was used,
being suggested by Dr. Upham. Ice to the head and sina-
pisms to the feet were also employed. A chloroform epithem
to the epigastrium in one case quelled pain, and convulsions,
and procured some sound sleep. The patients, three in num-

CEREBROSPINAL MENINGITIS. Ill

ber, which came under Dr. Borland's care, were stimulated
and nourished as highly as possible.

Remarks. By a singular coincidence, the five cases at the
City Hospital all occurred on the same side of the same
ward, at about the same time. The windows on this side of
the building look towards a piece of wet miry ground, but
were closed when these cases occurred, as it was in the win-
ter season. All the wards of the hospital are supplied with
fresh air pumped through the heating apparatus from one
and the same source — an aperture of entrance directed towards
the hills of Roxbury, and away from the miry ground just
mentioned. The cases occurred in patients convalescent
from other diseases, except one who had pneumonia at the
time the cerebro-spinal meningitis set in. " Their severity,"
says Dr. Borland, " in the three last at any rate, was propor-
tionate to the constitutional strength of the patients. They
all had intense spinal pain and tenderness, headache, and
prgecordial pain. Their positions in bed were very similar.
There was likewise a similarity in the almost unconquerable
constipation during the severity of the sickness ; and the
marked relapses of each of the three after convalescence were
apparently well established. They were daily seen by Dr.
Upham, who recognized them as the same disease he had
seen so much of in the Stanly Hospital.

XLII. Cases at Gallop's Island, reported by Dr. Calvin
G-. Page, Post Surgeon.

Remarks. In the case where opisthotonos was replaced
by emprosthotonos, the body was bent not only forward but
to one side, so that the patient was made frequently to roll
over to that side and out of bed.

In several among the fatal cases, the symptoms were im-
perfectly developed. But " by exclusion " they were classed
with the others. Dr. Page says, that other cases also, but
of a mild character, occurred, though they hardly deserve
mention. He adds that erysipelatous eruptions occurred on
the third or fourth day of attack (in those of course who

112 REPORT.

lived long enough) ; and further, that in all cases where the
patient was conscious, soreness of the limbs and feet prevail-
ed. In most cases there were involuntary discharges from
the rectum and bladder.

XLIII. Cases at Fort Warren — reported by Dr. Joel
Seaverns, A. A. Surgeon U. S. Army.

Remarks. Dr. Seaverns says two features have particu-
larly struck him, as worthy of mention in the history of his
cases — the one, an excessive cutaneous sensibility at the
outset of the disease, to such a degree that the patient, even
when almost in a state of syncope, shrieks and cries out at
the most trifling pressure : the other is the tendency to
relapse which seems to be, says Dr. S.,in a degree periodical,
so that the patient, if he survive the first invasion, becomes
apparently convalescent by the third or fourth clay, to be
again much worse after a week, when another improvement
occurs, and a second relapse ; and so on, till the patient's
strength becomes exhausted.

The case reported as of thirty-seven days duration sur-
vived several of these renewed attacks, and at length died
from the exhaustion consequent thereon, and a parotid ab-
scess ; having been repeatedly convalescent as it seemed.
Each of these relapses commenced with severe pain in the
back of the head and neck, followed by delirium, and increase
of fever.

KESULTS OF AUTOPSIES IN MASSACHUSETTS.

Autopsies in Massachusetts, as elsewhere, have been few
in this disease. All that we have collected, however, from
this State, in well marked instances of the disease, tell the
same story of meningeal inflammation. A summary of them
would be but a repetition of what is contained in the descrip-
tions quoted in the earlier part of this report.

CEREBROSPINAL MENINGITIS. 113

RESULTS OF TREATMENT IN THE TABULATED

OASES.

Setting aside the treatment by ergot (in three cases at the
City Hospital in Boston) and some matters of detail, we may
say that the following have been the modes of treatment
resorted to in our collection of cases, viz. : antiphlogistic ;
stimulant and supporting; that of liberal drug medication;
perturbating ; expectant. But, we are unable to generalize
in favor of any of these. That which has been followed by a
happy termination in one group of patients, has, in another
set, been less fortunate.

THE INVASION OF THE DISEASE.

Although, as we have before remarked, we desired to make
the list of queries in the circulars as short as the purpose of
our inquiry would admit, we regret that we did not put the
question whether the invasion of the disease was sudden or
otherwise.

We however take the liberty of supplementing the defi-
ciency on that point by borrowing the following statements
of the results of investigation of the subject, by M. Tourdes,
in France. One paragraph we translate from the " Compend-
ium de Medecine Pratique," by Monneret and Fleury, as
follows :

" It has been generally said that the approach of epidemic
meningitis is not announced by any precursory symptom.
M. Tourdes declares, on the contrary, that it is far from true
that the patient is invariably struck down at once (que l'in-
vasion foudroyante est loin d'etre constante) ; that such an
event is the exception, and not the rule ; and that it took
place in only a quarter or a third of the cases at most."

Valleix also quotes from the same observer — M. Tourdes —

as to the order of frequency of the precursory symptoms, as

follows: "Cephalalgia, 33 times; chills, 13 times; nausea

and vomiting, 13 ; rachialgia, 3 ; pains in the limbs, 2 ; ver-

114 REPORT.

tigo, 2 : general discomfort (malaise), 2 : diarrhoea, 2 : deli
rium, 1 ; trembling. 1 ; febrile movement, 1."

Dr. George G. Tucker, of Westfield, it will be recollected,
in his remarks on the sixteen cases famished by him for our
tables, gives a good description of the different modes of
invasion.

RELIABILITY OF THE CASES.

In stating the number of tovrns variously heard from, we
mentioned three as doubtfully reported. The cases from those
towns are not the only doubtful ones we have received, as
others have come in from places otherwise affirmatively
reported.

We have entered two or three cases on the ipse dixit of the
reporters, where we had no reasonable doubt of the accuracy
of the diagnosis. But we have taken the liberty of rejecting
in some instances, and we think the cases in the tables are
reliable. It must be remembered that spotted fever, or cere-
brospinal meningitis, presents different groups of its s}rmp-
toms in different subjects ; and therefore, though the symp-
toms set down in the tables may have been only partially, or
scarcely at all present in particular instances, yet, on read-
ing the accounts of the cases furnished us by their observers,
it may be obvious that they belong to the disease in ques-
tion. On one occasion, where certain cases looked bare in
the tables, we wrote to their reporter asking the grounds of
his diagnosis, and received in reply a graphic description
which left no doubt that the cases were properly included
in our list. Again, the symptoms, such as they are, are
sometimes imperfectly developed, and yet by the process of
exclusion the cases may be rightly classified with others of
the disease under consideration, as evidently belong nowhere
el<e. For example : Dr. Page says of his experience at Gal-
lop's Island, ••' in several among the fatal cases, the symp,
toms were imperfectly developed, but by exclusion they were
classed with the others."'

CEREBROSPINAL MENINGITIS. 115

We shall take occasion presently to offer an account of
certain doubtful or spurious cases. In the mean while we
give some additional cases, which arrived too late for inser-
tion in the tables.

ADDITIONAL CASES.

Five cases in Montague, Franklin County, reported by
E. A. Deane, M.D.

They were taken sick respectively January 16th, March
29th, April 13th, April 26th, May 4th, 1864. Dr. Deane had
no idea of the source of the disease. The cases showed no
preference for any particular locality — high or low, damp or
dry. They occurred in different parts of the town, which is
partly hilly and partly level, settled by a farming population.
They were in places rather sparsely settled. They made no
distinction between the wealthy or poorer classes. The ages
were eighteen, six, ten, twenty-one and forty-two years.
The disease seemed to prevail as an epidemic in this and the
adjoining towns. Dr. Deane saw other cases in consulta-
tion, in the surrounding villages.

The average duration of the cases was about three weeks.
The greatest duration was six weeks. The shortest duration
was, for the fatal cases, six days ; for those that recovered,
three weeks. Three of the five cases had convulsions.
There was headache in all — very severe in some of the pa-
tients. Four out of five were delirious. Some could not
give logical answers ; others could a part of the time. The
two that died had severe opisthotonos. It came on gradu-
ally, grew worse and worse till a short time before death. The
muscles all relaxed just before the patient ceased breathing.
Two of those that recovered had slight opisthotonos. Thus,
one of the patients was free from the symptom entirely. Dr.
Deane thinks nearly all had tenderness at the nucha. One
patient only had pulmonary or pleural symptoms. These
were very peculiar. The patient at one time would have all
the symptoms of severe inflammation and congestion of one

116 REPORT.

lung. In a few hours these symptoms would disappear, to
be replaced by symptoms referable to some other organ — the
heart, the liver, the bowels or the other lung. When the
thoracic or abdominal organs were involved, the head was
relieved. At one time the breathing was very much oppress-
ed, and there was bloody expectoration. In a few hours
bloody dysenteric discharges from the bowels set in. Then
all these symptoms would disappear, and the head symptoms
return. Petechial spots were frequently seen on different
parts of the body, varying in appearance : sometimes of a
scarlet redness, at others dark livid or purple. These
would appear and disappear at short intervals. For three or
four days during the second week, the whole surface was
quite yellow, having a very decidedly jaundiced look. This
patient recovered.

It does not appear in Dr. Deane's report whether the other
patients had petechias or not. Two cases terminated fatally ;
one on the seventh day, the other on the sixth day. Three
recovered, but very slowly

Autopsy in one case. There was inflammation of the me-
ninges, with abundant deposit of coagulable lymph, more
abundant at the base of the brain and near the foramen.
This extended down the spinal cord as far as examined.

Treatment. Dr. Deane adopted no definite plan of treat-
ment, but managed each case according to the indications
as they presented themselves. He used cold applications to
the head ; counter-irritation over the spine, with stimulating
liniments, mustard, or blisters : hydriodate of potassa and
opiates internally ; also expectorants, alteratives, cathartics,
astringents, tonics — as the cases seemed to require.

PROBABLE CASES.

"We have now to present two cases reported to the Boston
Society for Medical Improvement, in February, 1866, by
David W. Cheever, M.D., as probably instances of " cerebro-
s pinal meningitis. "

CEREBROSPINAL MENINGITIS. 117

Case XIII. Nov. 23d, 1865. Mr. G., about 40 years old,
of rather feeble physique, a stone polisher by trade, after
great exposure, was attacked with pain in back, nausea,
chill, and general febrile symptoms, on Saturday evening.
These symptoms continuing, I was called to him on Thurs-
day, Nov. 23d. He then had a feverish look, strong typhoi-
dal odor, coated tongue, back ache, and constant retching of
bilious matter; pulse not remarkable. This bilious vomit-
ing continued two days, when on Saturday it changed to
vomiting of blood. This was constant in large quantities,
fluid and not much altered by digestion, for two days. It
was uncontrolled by the remedies used. The spleen could
be felt much enlarged. Bowels otherwise not remarkable.
Mind clear, tongue brown and dry.

An eruption of violet-colored petechia? resembling typhus
appeared on back on Saturday, and became very numerous
over abdomen. He died on Monday, five days after I saw
him, eight days after first symptoms. No autopsy. Sur-
roundings of patient very bad. I regarded the case as malig-
nant typhus.

Case XIV. Cerebro- Spinal Meningitis, latent until twelve

hours before Death. — Miss , 50 years of age, fair health,

complained Monday, Feb. 19th, 1866, of pain in foot, back
and bowels, followed next day by nausea and vomiting ;
return of a pale discharge from vagina — menstruation having
ceased one year previous. This discharge lasted three days.
Wednesday evening, Feb. 21, 1866, ten o'clock, I saw her first.
She had just gone to bed, having been up all day. Aspect
a little flushed ; pulse 100 ; nervous, irritable ; complaining
of bilious retching. No dejections for some days. Flatu-
lence and pain in small of back. Ordered calomel and bi-
carb. soda3.

Thursday. Two sufficient dejections ; less retching and
flatulence ; aspect . about same ; very nervous ; restless ;
apparently exaggerates her troubles ; much rheumatism in
family ; complains of being unable to move freely on account

118 REPORT.

of her back, which is without feeling, she says, in lower
part ; somewhat painful ; not tender ; no paralysis of limbs
or face ; eyes natural ; no photophobia ; hearing normal ;
tongue moist, thin white coat ; pulse 100. Ordered 10 grs.
Dot. powder, liniment to back and hot drinks for diaphoresis.

Friday, A.M. — Vomited Dov. powder, and continued to
retch a good while — otherwise seems better ; skin moist,
tongue thin white coat, pulse 80 ; a little desire for food.
Says her back is better, and moves herself more freely.
Ordered beef-tea.

11 P.M. — Called to her again. A very little delirious —
coherent on being roused — complains that pain in back has
shifted to nape of neck ; restless, having had no good sleep
for several nights. Tongue same— pulse 100 ; skin soft and
moist. Ordered morphia, gr. -£, and repeat if necessary.

Saturday, 9 A.M. — A bad night; restless, delirious; pain
in nape of neck severe ; jactitation ; entire incoherency ;
vague apprehensions ; seeking to avoid her attendants ;
creeping out of bed ; moves limbs freely ; no opisthotonos.
Pupils obey light ; tongue brown and dry ; pulse 130, weak,
and uneven ; subsultus tendinum. Urine passed voluntarily ;
abdomen not swollen. Aspect of grave disease. Prognosis
doubtful. Diagnosis — cerebro-spinal meningitis or malignant
typhoid.

11 A.M. — Seen in consultation by a gentleman of large
experience. To test the diagnosis from the history of the
case, this was detailed to the consulting physician by a rela-
tion who had attended the patient throughout, and the case
was closed with the events and treatment up to last evening.
The impression made on this gentleman was of a nervous
case, probably in great measure hysterical. On entering the
chamber he concurred with me in thinking she had but a few
hours to live, and that the case was one of cerebro-spinal
effusion. The patient was wholly insensible, lying on her
right side, breathing heavily, but without stertor ; covered
with perspiration ; tongue brown and dry ; mouth open ;
pulse 160, very feeble and thready. Right pupil widely

CEREBROSPINAL MENINGITIS. 119

dilated, and insensible to light; cornea looking as if breathed
upon ; left pupil natural, and responding sluggishly to light.
Nothing abnormal in lungs or heart ; bowels soft and not
tympanitic ; face a little drawn to right side ; limbs not
paralyzed ; no opisthotonos ; no petechias. In this condition
she remained until she expired in a convulsion at 3 P.M.
No autopsy could be obtained. The surroundings of the
patient were of the best description. No other cases have
been reported in that section of the city ; and she herself
was in average health, the week previous, and up and about
her chamber sixty hours before her death. Can any other
solution, says Dr. Cheever, of the problem, be offered so
probable as cerebro-spinal meningitis ?

Case XV. Blindness as a sequela of probable Cerebrospinal
Meningitis. Case furnished by Dr. H. W. Williams, of
Boston.

A young man of sixteen years, well developed and of very
strong constitution, was seen on the 11th of March, 1866.
The account given of his previous symptoms was, that he had
been suddenly attacked about five weeks previously, with
severe cerebral symptoms, accompanied by an appearance of
spots all over the skin. He continued unconscious about a
week, when he began to improve, and from that time gained
rapidly. No further history of the case was obtained except
that his eyes remained staring open during much of the period
of delirium, and they were from that time greatly injected.
His medical attendant had not, however, supposed the symp-
toms in his eyes to be serious, until alarmed by the appear-
ance of matter in the anterior chamber of the right eye.

On examination it was evident that a deep-seated exuda-
tion, of a yellowish color, existed in both eyes. In the left
eye the iris had lost its healthy aspect, and the edge of the
pupil was extensively fastened by adhesions to the capsule
of the lens ; but, as in the other eye, the crystalline remained
transparent. In the right eye the iris had a more healthy

120 EEPOET.

look, though some adhesions existed. It seemed as if the
matter in the anterior chamber had its origin in the collection
near the fundus of the eye, and had found its way through
the pupil. Scarcely a perception of light remained.

Case XVI. Reported to the Boston Society for Medical
Improvement, May 9, 1864, by Dr. 0. Ellis. Symptoms of
Cerebrospinal Meningitis ; doubtful appearances of Disease of
the Pia Mater of the Brain and Spinal Cord.

A child, seven years of age, was attacked eleven weeks
before death with fever and pain in the frontal region. Ten
days after the commencement of the disease, the head was
drawn strongly backwards, and opisthotonos became so
marked that the shoulders did not touch the bed. This con-
tinued until three weeks before death. The pupils were
dilated from the commencement until the last day, when they
became contracted. Though delirious, the child could always
be roused. The pulse at the outset was extremely rapid,
hard, full and strong, and so continued for more than six weeks,
when it became nearly natural. No nausea nor other symp-
toms referable to the digestive organs. No chills. No pete-
chias until towards the close, and then only to a slight extent.
The above were the principal symptoms, obtained from Dr.
Holmes, of Milton, who had charge of the patient. There
were no special changes towards the close, and death seemed
to result from exhaustion.

On examination of the head, the arachnoid was found dry,
and the convolutions somewhat flattened. The lateral ven-
tricles contained from four to six ounces of clear serum.
The membranes of the base had a slightly opaque appearance,
and were somewhat infiltrated, but there were no miliary
granulations nor other evidences of disease. The arachnoid
and pia mater of the spinal cord were perhaps opaque, and
somewhat peculiar, but neither the changes here nor in the
membranes of the brain would have attracted special atten-
tion, had it not been for the epidemic of cerebro-spinal menin-

CEREBROSPINAL MENINGITIS. 121

gitis prevailing at the time. The thoracic and abdominal
viscera were not examined.

The case was regarded as interesting, says Dr. Ellis, inas-
much as morbid appearances not unfrequently met with were
accompanied by symptoms which pointed to a lesion of the
membranes of the brain and spinal cord, and yet the latter
could not be clearly shown to exist. May it not indicate,
he asks, that the symptoms of ordinary disease can be modi-
fied by the prevailing epidemic influence, although peculiar
lesions are not satisfactorily made out ?

DOUBTFUL OR SPURIOUS CASES.

It having been alleged that the disease under consideration
has prevailed at Amherst College among the students, we
present the following note we have received in relation to
the matter.

11 Amherst College, August 8, 1865.

"Dr. Parks, — Dear Sir: I answer your printed inquiries
not so much because I can give you any light that you ask for,
but merely because we have had a disease in our College,
which our older physicians, for want of a better name, have
termed meningitis.

"For the past two years here, in College — and especially
during spring and summer — several of our students have been
affected with something like the following symptoms. An
intense pain all over the head, and in some part of the spinal
cord — generally the upper. This is accompanied by great
prostration, and in the worst cases study has been out of the
question. All the other functions are maintained with regu-
larity, and never has there been anything like delirium or
convulsions attending the disease.

" Belladona has generally had a good effect, and large
doses of whiskey also. And in the worst case we had, whis-
key would always reduce the pulse as long as the effect of it
lasted. * * * * Yours, truly,

(Signed) "E. Hitchcock."

122 REPORT.

We shall not assume to pronounce upon the cases at
Amherst College ; but they remind us that more than one
observer of spotted fever, or cerebro-spinal meningitis, has
reported having seen, during the prevalence of the disease in
his neighborhood, mild cases, or cases "not worth mention-
ing," that were, as we infer, instances of the existing epi-
demic, or colored by the prevailing epidemic influence.

PATHOLOGY.

We come now to the question what, in the light of present
experience, is the " spotted fever," otherwise termed " cere-
bro-spinal meningitis " ? As in the case of the epidemic of
1806 to 1815, we must reply that it is easier to say what it is
not, than what it is.

Discarded opinions. Various fallacies as to the pathology
of the disease — for example, its location among the exanthe-
mata— having soon died out, the idea of its having been a
form of intermittent or remittent was started, but seems now
to have been laid aside, and for reasons already given.

The Typhus Theory. There are some who still regard the
disease as a form of British Typhus. In France, M. Boudin
declares that cerebro-spinal meningitis is nothing but a species
of typhus fever, and assigns to the affection the name of
cerebro-spinal typhus — a term somewhat similar to that used
by some among the Germans— cerebral typhus. Valleix re-
marks that the memoir of Boudin would strongly incline us
to admit that many epidemics denominated typhus were epi-
demics of cerebro-spinal meningitis, but that such admission
is a different thing from the adoption of the writer's conclu-
sions. As to the facts, he says, presented in former writings
and supposed to have a bearing upon this question, they are
neither sufficiently detailed, nor precisely enough stated to
be of real utility in the investigation of it.

In this country, Dr. Baltzell, in the October number of the
American Journal of Medical Sciences for 1865, enters into
an elaborate comparison of the spotted fever with typhus, to

CEREBROSPINAL MENINGITIS. 123

show the resemblances between them. In relation to the
spots, Dr. Baltzell finds that of 2*7 cases of spotted fever there
were pelechice in a little over 61 per cent. He then shows
that in Payer's 194 cases of typhus, the percentage of pete-
chia* was 80 ; in Gerhard's 36 cases it was 88 ; in Stoker's
540 cases, a little over 71 ; the average percentage of the three
observers being, as we make it, nearly 80. Dr. Baltzell claims'
that the difference (18|) in the percentage of petechias between
spotted fever and typhus, is not sufficiently great to separate
the two diseases ; especially, he says, since ecchymosis, vibi-
ces, efflorescences, &c, have been seen in cases of typhus, as
well as in spotted fever. In our Massachusetts statistics of
spotted fever, we will remark, by way of parenthesis, the pro-
portion of petechias or analogous spots was somewhat less
than 59 per cent, of 250 cases competent to be reckoned upon.

On the other hand, however, in a German epidemic of
cerebro-spinal meningitis, referred to by the editor of the
British Medical Journal, no eruption in the slightest degree
analogous to the typhus rash was met with in any instance ;
while another eruption — herpes labialis — was observed in
the greater number of cases.

Dr. Stille remarks that the spots would seem not to belong
essentially and exclusively to any disease, but to indicate a
certain condition o\ the blood, and also perhaps of the solids ;
since they are liable to occur in other diseases, as yellow
fever, scurvy, purpura, &c.

Professor Murchison, Physician to the London Fever Hos-
pital, one of the chief authorities on typhus fever, takes
ground in favor of the identity of " spotted fever " and ty-
phus in the following line of argument.

" It is well known," he says, " that among the phenome-
na of typhus the cerebro-spinal symptoms hold a very promi-
nent place. First, there is headache, with vertigo and in-
jected conjunctivas ; then come restlessness, sleeplessness
and delirium, followed by stupor or coma. With these symp-
toms may be associated paralysis of the sphincter or of the
detrusor muscles of the bladder, hyperesthesia, tremors,

124 REPORT.

floccitatio, subsultus, or general convulsions, strabismus,
tetanic rigidity of the muscles of the limbs, or even opistho-
tonos. Occasionally typhus commences with yiolent deliri-
um, and other cerebral symptoms, so that more than once I
have known it mistaken for acute mania.'7 * * *

" Among the most common anatomical lesioDS of typhus,
are engorgement of the venous sinuses of the dura mater,
increased vascularity of the pia mater, and an accumulation
of serous fluid in the ventricles, and in the subarchnoid space
of the brain and cord.

"It is not many years since these symptoms and lesions
were believed to be the result of inflammatory action in the
membranes of the brain and cord, and the treatment of typhus
was based upon this belief. But the researches of John
Reid and of all subsequent observers have demonstrated that
there exists no relation whatever between the decree of vas-
cularity and the amount of sub-arachnoid fluid on the one
hand, and the severity of the cerebral symptoms during life
on the other, while it is now universally admitted among
pathologists that the lesions of typhus are quite independ-
ent of inflammatory action. This is the result of my own
observations : and the investigations of John Reid, Peacock,
Jenner, Jacquot, Barrallier, and of all modern observers who
have had much experience in the post-mortem examinations
of typhus, lead to the same conclusion." * * *

" But, to the rule above laid down, there are exceptions.
In rare cases typhus fever is complicated with unmistak-
able inflammation of the membranes of the brain. At the
time of publication of my work on Fevers, I was under the
impression that this complication never occurred, but subse-
quent experience has convinced me that I was mistaken. In
the interval I have met with two unequivocal cases of typhus
complicated with true meningitis and the effusion of lymph
on the surface of the brain." * * *

The drift of the argument here seems to be, that in respect
of the morbid appearances within the cranium, spotted fever
and typhus stand upon the same footing.

CEREBROSPINAL MENINGITIS. 125

"It is possible, " the Professor continues, "that some of
these epidemics [meaning epidemics of alleged cerebro-spinal
meningitis] were really examples of primary inflammation of
the cerebral and spinal membranes ; but when this seemed
to be the case, it is to be noted that the persons attack-
ed were comparatively few, that no eruption appeared on
the skin, and that there was no evidence of the disease
being infectious. I would instance in particular the epide-
mic described by Dr. Mayne, as attacking children in seve-
ral of the Irish workhouses in 1846, with regard to which
the absence was noted of any proof that it has ever been
propagated by contagion." * * *

" If to the above characters [the symptoms and morbid
appearances of the present epidemic, including the alleged
occasional absence of traces of meningeal lesion] be added,
the fact that its contagiousness is a disputed question, and
that it has been found to prevail chiefly under circumstances
of over-crowding and inadequate ventilation, it cannot be
surprising that many American physicians admit the close
relation of cerebro-spinal meningitis to typhus, while some
maintain the identity of the two diseases. It may be well
therefore to consider the four points of distinction between
them, laid down by Dr. Lidell, and in doing so I adopt the
writer's own words :

" 1. ' Spotted fever often runs its course in a few hours.
Typhus requires at least several days.' The rapid course of
many of the American cases, and of epidemic cerebro-spinal
meningitis generally, is no doubt remarkable, but is not suffi-
cient to found a distinction, for many cases of typhus are on
record where the disease has terminated fatally on the second
or third day, or even after a few hours." * * *

''' 2. ' Spotted fever is frequently attended with convul-
sive movements ; typhus fever is never so accompanied/
My experience of typhus is precisely the reverse. Convul-
sive movements are not uncommon.77 * * *

"3. ' Spotted fever patients often die suddenly and un-
expectedly of coma and asphyxia ; typhus patients do not

126 REPORT.

die in this way.' According to my experience of typhus,
the most common mode of death from the primary fever is
by a combination in various proportions of syncope and
coma. A large proportion, also, of fatal typhus cases are
complicated with pulmonary disease, and then death occurs
by coma and asphyxia. Moreover, I have repeatedly known
patients who appeared to be going on well, become suddenly
comatose, and die in a few hours."

"4. ' The eruption in spotted fever frequently appears on
the first day ; while in typhus the eruption does not appear
till the end of the week or more.' According to my experience,
the eruption of typhus usually appears on the third and
fourth day, is rarely delayed beyond the sixth day, and may
sometimes be noted on the second day. It is well known
that in severe cases of most blood diseases petechias may
appear as early as the first day. The sooner the eruption of
variola appears, the more grave is the case."

Professor Murchison expresses the opinion that " the
grounds for drawing a specific distinction between the epi-
demic cerebro-spinal meningitis or spotted fever of America
and typhus fever, are most inconclusive, and particularly
when it is recollected that typhus fever, running the ordinary
course, has been prevailing in many parts of America since
the commencement of the present war. I agree entirely
with the opinion expressed by Dr. Upham." The Professor
then quotes from Dr. Upham's paper on the disease at New-
bern, in which monograph the opinion approved by the for-
mer is stated in these words : "The disease seemed to me
rather to partake of the nature- of typhus in a severe and
malignant form, * * * having in this instance a special
direction to the meninges of the brain and spinal cord." Dr.
Murchison pays a just tribute to the ability of Dr. Upham's
memoir.

It is not our province to enter into the discussion of the
pathology of the disease, but it is perhaps our duty, as re-
porters, to note that where Professor Murchison says that the
contagiousness of spotted fever is a disputed question, the

CEREBEO-SPINAL MENINGITIS. 12 7

medical profession of this country should have been excluded
from the list of disputants, since its non-contagiousness is
very generally taken for granted here. Again, in stating
that the disease has been found to prevail chiefly under cir-
cumstances of over-crowding and inadequate ventilation,
the remark is hardly applicable to the United States, where
in civil practice the reverse- has been the rule. The learned
Professor, we presume to suggest, may have been laboring
under some confusion in classing together, as he does in his
paper, the American with some other European epidemics,
and with the Russian Plague.

Further, Dr. Murchison mentions the cerebro-spinal menin-
gitis of the Irish work-houses in 1846, described by Dr.
Mayne, as an example of " some epidemics " which he thinks
were possibly real instances " of primary inflammation of the
cerebral and spinal membranes." The absence of eruption
in, and the non-contagiousness of the Irish cases, tally — the
former with what has often — the latter with what has gener-
ally— been noticed in this country. And, the cerebro-spinal
meningitis of Dr. Mayne has frequently been quoted by
American writers as a disease, the counterpart of our " spot-
ted fever." We will venture, also, one more criticism. It
seems to us that Dr. Murchison compares what is the excep-
tion in typhus with that which is the rule in spotted fever.

We can conceive that on the negative side of the question
of the connection of " spotted fever" with typhus, the same
line of argument may be used as that of Dr. Holmes in speak-
ing of the epidemic of 1806 to 1815 — that a disease which
is sometimes almost as sudden in its invasion as a stroke of
lightning ; which is rarely suspected of being contagious ;
which gives us a solitary case in a ship of war, a single
case in a boarding school, two cases only in an almshouse ;
which in civil practice affects the villages and isolated farm-
houses of the interior (where typhus " running the ordinary
course " is unknown) as much at least as the large cities ;
which in a great majority of cases is fatal in a few days or
even hours \ the mortality of which is very variable : such

128 REPORT.

a disease presents so many points of difference, when com-
pared with British typhus, that we should hesitate before pro-
nouncing the two identical.

In fact, the editor of the British Medical Journal, comment-
ing-, in the number for July 8th, 1865, on Dr. Sanderson's de-
scription of cerebro-spinal meningitis in Germany, contrasts
the differences between that and typhus, with the result that
" it is impossible to place the two diseases next to each other
in the nosology, much less to admit their identity/'

The Inflammation Theory. Among those by whom the
typhus and other above-mentioned theories are disowned, 'the
question of the pathology is narrowed down to this alterna-
tive, viz. : either it is a form of cerebro-spinal meningitis
(typhoid, some would say), or else it consists in its essential
nature and primarily of some occult change, other than
typhus — some alteration of the fluids or solids of the econo-
my— the meningeal lesion being a secondary phenomenon.

The former view is maintained by Dr. Stille, and others,
who hold that meningeal inflammation is declared by the
symptoms and post-mortem appearances.

As bearing on this side of the question, we translate from
the " Compendium de Medecine Pratique " the following
analysis of blood taken from patients with cerebro-spinal
meningitis.

"The blood was rarely buffy. In cases where there was
a buffy coat, it was thin, variegated, imperfect. In the dead
subject the blood was remarkable for the abundance and
the density of fibrinous clots. The blood was submitted to
analysis according to the process suggested by M. Dumas,
and followed by MM. Andral and Gavarret."

CEREBROSPINAL MENINGITIS. 129

First Experiment, second Day, third Bleeding.

Fibrine,

4.60

Globules, .

134.00

Solid matter from serum ,

71.16

Water,

790.24

1000.00 parts of blood.
Second Experiment, second Day, firsi Bleeding.

Fibrine, . . . 3.90

Globules, . . . 135.54

Solid matter, . . . 79.64

Water, . . . 780.92

Third Experiment, second Day, first Bleeding.

Fibrine, . . . 3.70

Globules, . . . 143.00

Solid matter from serum, . 58.50

Water, . . . 794.80

Fourth Experiment, third Day, second Bleeding.

Fibrine, . . . 5.63

Globules, . . . 137.84

Solid matter, . . . 60.33

Water, . . . 796.20

" It will be seen/' the writer continues, " that the quan-
tity of fibrine is between 3.10 and 5.63 ; that is to say, be-
tween a minimum,* which is already a pathological condi-
tion, and the figure which is only reached in well-marked
phlegmasia." * * * " The decided increase in the
fibrine is an experimental result of great importance, and
one which assigns to epidemic cerebro-spinal meningitis the
rank occupied in nosography by the phlegmasia of the serous
membranes. But the epidemic constitution impresses upon
these phlegmasia a more rapid march, and a greater gravity

* Iu Carpenter's Physiology we are told of a healthy specimen of blood giv-
ing, by each of four different methods of analysis, 1.56 parts of fibrine in a thou-
sand ; another specimen, 1.95 parts, by all the same four methods of examina-
tion. Carpenter estimates the average amount of fibrine in health on the basis
of the analysis of Lehmann (quoted also by Dalton), who makes the proportion
of fibrine in the plasma alone of the blood, to be 4.05 parts. As the plasma con-
stitutes about half the entire volume of the circulatory fluid, Carpenter sets the
proportion of fibrine in the latter at 2.025 parts in a thousand.

130 REPORT.

than obtains in sporadic inflammation of the meninges. That
is the only point in which they appear to us to differ from
the latter. [?] In a case of cerebro-spinal meningitis, MM.
Andral and Gavarret ascertained an increase in the fibrine of
the blood.

"There have been found in the heart and large vessels
fibrinous clots, thick, yellowish, quite adherent to the colum-
ns carneae. Some authors, it is true, speak of fluidity of
the blood ; but their observations are wanting in detail. "

The opponents of the theory that the inflammation in spot-
ted fever is the primary pathological fact, claim for the sup-
port of their position : first, the different behavior of the
disease from that of ordinary meningeal inflammations ; sec-
ondly, the futility in that malady of all the means usually
more or less influential in combating such inflammations ;
thirdly, the occasional occurrence of cases, at the autopsies
of which no morbid appearances within the cranium have
been detected.

The first point — the different behavior of the disease in its
course from ordinary meningitis — will perhaps be explained
by the typhoid character of the epidemic. The second point
— its resistance of the ordinary remedies of meningeal inflam-
mation (always provided it be proved that it is never bene-
fited by depletion) — may also, perhaps, be disposed of in the
same way.

It remains, therefere, to consider the allegation that there
have been cases in which no traces of meningeal inflamma-
tion were found on post-mortem examination. If such cases
can be fully made out, they will afford very strong ground
for the opponents of the theory that the inflammation is
primary. Cases VI. and VII., pages 45 and 47, are in point.
In those, we are told, no traces of inflammation within the
cranium were detected. It would have been more satisfac-
tory, however, if it had been definitely stated whether there
were or were not dryness or opacity of the meninges. Those
changes were found without other lesion in some of the more
rapid and violent cases reported by French authors, by whom

CEREBROSPINAL MENINGITIS. 131

they were yet considered instances of cerebro-spinal menin-
gitis. Instances occurred, too, it will be remembered, in the
old New England epidemic, where, in rapid cases, only tur-
gescence of the cerebral vessels was found ; whence the ob-
servers concluded, not that inflammation was absent, but that
it had not time to develop so as to leave traces evident to
the eye. But we may appropriately introduce here the con-
cluding portion of a letter (already referred to), kindly for-
warded to us, at the request of Surgeon General Barnes, by
Assistant Surgeon J. J. Woodward, Brevet Major IT. S. A.

" A large number of interesting histories of cases and ac-
counts of autopsies have been collected from the reports of
medical officers, and several specimens of the brain and spi-
nal cord, in these cases, have been received at the Army
Medical Museum. The medical history of the war, now
preparing in this office, will contain a careful discussion of
this material, which is not yet ready for publication. In a
general way, however, I am permitted to inform you, that
there were at least two classes of cases brought under the
observation of this department. In the first, the autopsy
disclosed grave anatomical lesion of the cerebro-spinal axis,
accumulations of serum, sero-pus, pus, or tough yellow
lymph, especially in the ventricles about the base of the
brain, and in the upper part of the spinal canal. In the sec-
ond class of cases, no perceptible anatomical lesion in the
cerebro-spinal axis was observable. These two groups of
cases rest upon equally reliable evidence, and are not to be
disposed of on the supposition that the latter represent mere-
ly an early stage of the former, since it is to be remarked
that both anatomical conditions appear to have been found
indifferently in protracted cases as well as those which prov-
ed suddenly fatal. For a full discussion of this interesting
subject I must ask your patience until the official publication
of the medical history of the war. A judicious compilation
of the experience of the medical department, as to any one
disease, is not possible until the exhaustive examination of
all the records of the office now progressing is completed,

132 REPORT.

since at every step new facts are acquired, and the prema-
ture publication of fragmentary and incomplete information
would be the more deplorable, as a comparatively brief peri-
od will bring the whole into a proper shape for communica-
tion to the medical world/7

We await with great interest the publication of the valua-
ble work referred to in the preceding extract. When that
shall appear, the morbid anatomists will probably tell us
what interpretation to put upon the results of the autop-
sies. We therefore here leave the question — whether or not
the inflammation in spotted fever is primary — subjudice. But
in the mean while we may state some of the theories held
among those who advocate the negative side of the question.

Further Statement of Opinions concerning " Spotted Fever."
— Some of those who deny that the inflammation in the dis-
ease before us is the primary pathological fault, claiming that
the fons et origo mali is behind the inflammation — as for ex-
ample in the blood — are disposed to classify cerebro-spinal
meningitis with certain other affections corresponding more
or less with it, but in which the local manifestations during
life and after death relate to other tissues or organs than the
meninges. Especially has it been assimilated to typhoid
'pneumonia. In casting about for leading facts which might
bear upon this theory, we came across the following, which
we offer in its behalf, so far as relates to the affection last
mentioned.

One of our Massachusetts correspondents has mentioned
that the spotted fever in his town was followed by an epi-
demic of typhoid pneumonia, in which there was great corres-
pondence— mutatis mutandis — in the symptoms of the two
sets of cases. In like manner the old spotted fever, so-called,
was followed in a portion of New England by an epidemic of
typhoid pneumonia, in which, as Dr. James Jackson informs
us, there was a good deal of similarity between some of the
leading symptoms and those of the recognized spotted fever
of that day.

CEREBROSPINAL MENINGITIS. 133

Dr. Burne, of the Westminster Hospital, England (as Dr.
Condie states in his edition of Watson), mentions that a great
number of cases of what he calls the " spotted fever ;; were
brought into that institution in the year 1838. He describes
the affection as " an adynamic or typhus fever, combined
with a latent and dangerous pneumonia, and exhibiting on the
surface a very regular and uniform spotted eruption — not
petechias ."

On searching the pages of Grisolle for information on the
subject, we found a description of an epidemic of typhoid
pneumonia observed by himself. He mentions having seen
in some of the cases petechia? and ecchymoses. Grisolle strikes
the key-note of our modern " Humorists/7 when he says that
judging only by the cases he had observed, the intensity of
the typhoid symptoms was almost always in inverse propor-
tion to the space occupied by the pneumonia ; a circumstance
demanding, he asserts, the admission that the pulmonary in-
flammation constituted only an epiphenomenon, and that it was
the consequence of some general alteration of the solids or fluids
of the economy.

In this connection it may also be interesting to recall the
apparent metastasis from the head to the lung, and thence to
other organs, with subsequent return to the head, in one of
the five additional cases from Montague contributed by Dr.
Deane. (Pages 115, 116.)

The theory in support of which we have collated the pre-
ceding facts (without intending, however, to mingle in the
discussion), sets forth that in the so-called epidemic cerebro-
spinal meningitis, and in typhoid pneumonia, &c, an essen-
tial disorder common to them, and assumed to be behind the
inflammation, manifests itself, now in the head and spinal
canal, by cerebro-spinal meningitis, now in the chest by
typhoid pneumonia, and so on ; and that the inflammation in
the affections thus affiliated to each other bears the same re-
lation to the essential disorder, that the sore throat in scar-
latina bears to the general affection of the system in the lat-
ter disease. At least such seems to us to be the drift of the
theory.

134 EEPORT.

Dr. Levick (in the American Journal of Medical Sciences;
No. 48, page 139) states it as his belief that there is an epi-
demic influence which shows itself in its mildest form as in-
fluenza ; again as typhoid pneumonia ; once more as cerebro-
spinal meningitis ; while in some cases the blood itself ap-
pears to be greatly affected without presenting at once the
phenomena of disease of any special organ.

Connection with Diphtheria. Finally, diphtheria has in the
same way been associated by some with cerebro-spinal me-
ningitis.* Those who favor the theory of connection be-
tween these two diseases, are entitled to the benefit of the
following facts reported on previous pages.

Dr. C. E. Ware says in his remarks (No. XXXIV.) on his
cases, in several of them (seven in number) " diphtheria un-
equivocally existed. In one family where there were four
cases unquestionably of the same disease" [spotted fever or
cerebro-spinal meningitis], " the petechial eruption and the
diphtheritic condition of the throat existed in some but not
in all." It is fortunate for the cause of science that these
cases fell into the hands of one whose diognosis is above
question.

Dr. L. E. Marsh, of Granby, also says, "in one case, a
girl of 15, there was complication with diphtheria."

A case, not quite so much in point, perhaps, but highly
interesting, was reported by Dr. W. W. Greene, of Pittsfield.
After remarking that the exudation [seen upon the meninges
at his autopsies resembled very much that of diphtheria,
Dr. G. says one man was violently attacked with cerebro-
spinal symptons, and abundant spots lasting for two days,
when a copious exudation occurred in the throat, " and all
the pain, delirium, opisthotonos, tenderness, &c, disap-
peared."

* We would refer here to the statement of one of the writers on the old spotted
fever,, that he generally found soreness of the throat in his cases when he looked
for it.

CETIEBRO-BPINAL MENINGITIS. 135

We would remark that the co-existence of spotted fever
or cerebrospinal meningitis with diphtheria, typhoid pneu-
monia, &c, does not appear to tho writer to necessitate the
supposition that these affections are manifestations of* zymotic
or other general disorder behind thorn ; but is equally well
explained, perhaps, by the theory of simple typhoid inflam-
mation.

One other- hypothesis which wo have never soon distinctly

set up, scorns to have been shadowed forth in some state-
ments of mots. It is this : that while the true epidemic is
purely a form of ccrebro-spinal meningitis, there have been
cases which have passed for instances of it, but which really
consisted in other morbid conditions, modified or colored, as
it were, by the prevailing epidemic influence. This would
be an easy method (perhaps too easy) of explaining the cases
mentioned on preceding- pages, in which the post-mortem
appearances were less indicative of meningeal inflammation
than the symptoms.

DIAGNOSIS.*

Typical Cases, Observers will, we believe, concur in the
Statement that while all the symptoms are not represented
in any one case, probably no two oases have the same groups
of symptoms. A disorder, then, the pathology of which is
undetermined, and in which the groups of phenomena are
various in different individuals, would seem to be difficult of
recognition. Yet, when fully developed, it need hardly be
mistaken ; and, as a general thing, those who have seen cases
will, we think, know it when they meet with it. Its combina-
tions of symptoms, when well declared, are peculiar ; cluster
around the cerebro-spinal axis, and are usually very rapid in
their invasion. Also, the "process of exclusion ;; is of
much avail.

* Sec Appendix A.

136 REPORT.

. - ses Masl ml at the time of Invasion. When, however, the
invasion is not sudden, as frequently happens, the formative
stage may be insidious. If, then, the affection in question
being prevalent, a person complains of headache, chilliness
and nausea, not traceable to some other source, the physi-
cian, we would suggest, should be on the alert for this dis-
ease. Other symptoms, also, referable to the cerebro-spinal
axis, and not pointing clearly to a different cause than the
disorder under investigation, may be looked upon with
suspicion.

Obscure Cases. But sometimes the symptoms are obscure
during a great part or the whole of the disease, as in Case
XL, page 56. When this is the fact, we know of no better
guide than a careful comparison of the symptoms with the
admirable description of them by Dr. Upham (quoted on
page 22), and with other recorded cases. In rare instances,
perhaps, where this disease is suspected, doubt will be the
only rational opinion.

PROGNOSIS.

If the behavior of spotted fever or cerebro-spinal me-
ningitis in this State be an index of its general course, we
may deduce the following corollaries from our statistics
of its duration and termination. First, the prognosis, during
the first few days, at least, is grave; secondly, after four
or five days have elapsed, if fatal symptoms be not pre-
sent, the prospect becomes more hopeful ; thirdly, the pa-
tient is not safe, even in convalescence, since there have been
instances of fatal relapse.

THE NOMENCLATURE

Waits upon the pathology. With those who hold that the
disease, on which we have been reporting, is a form of typhus,
it has already been generically named. The views of some
would, perhaps, be comprehended under the term Typhoid

CEEEBBO-SPISAL XESTSGIZ 137

Others would seem to consider " "
a peculiar Toxwnria. But, till the pathology be better §et-
tlei than at present, we shall probably continue to s]
of " Spotted Fever," or sdro- Spinal Jfeninc

The Repc: pectfully submit:

jmmit:

LUTHER PARKS, Jb,, M.D.

(TTiairmari.

Borrox, May, 1;

APPENDIX.

At our request, Dr. 0. G. Page, of this city, sent us the
following note upon the diagnosis of the disease treated of
in the Report.

" Boston, July 16, 1866,

" Dear Dr. : — There is a single point in relation to cases
of Cerebro-Spinal Meningitis, as they have occurred under
my observation, that deserves to be recorded.

" I refer to the very great difficulty in distinguishing the
disease in its incipiency from the lighter forms of febrile
attacks, or from simple disturbance of the system by slight
indigestion.

" Several of my cases presented this condition. One espe-
cially I recall, where there was only a general feeling of
malaise in the morning, the patient having been perfectly
well the day previous ; at noon he was prostrate, and at
night he died. I know of no means by which the disease
could have been recognized when this patient first presented
himself. Yet at noon it was clear enough. The knowledge of
other cases existing, or an epidemic tendency to febrile dis-
eases, should put us on our guard against giving careless or .
hasty opinions, in all cases where there is in our own minds
the slightest doubt in relation to the simple symptoms first
brought to our notice, and prognosis should be very guarded.
I doubt whether, in the case alluded to, had the disease been
recognized in the morning, medicine or treatment would
have been of value. Yery truly yours,

"Dr. L. Parks. Calvin G. Page."

140 APPENDIX.

We received (too late to embody in the Report) from Wil-
liam Lester, M.D., of South Hadley, a circular from which
we derive the following four cases. They occurred in Gran-
by and South Hadley ; in December 1864, March 1865, Jan-
uary 1866. Dr. Lester had no idea of the source of the dis-
ease. It showed no preference for localities " high or low —
damp or dry"; "districts thickly or sparsely settled";
" the wealthy or the poorer classes." Three of the patients
were adults. The average age was 26 years. The greatest
age was 60 years, the earliest age 4 years. There were no
evidences of contagion. The average duration of the cases
was about 8 weeks ; the greatest duration, 16-17 weeks ; the
shortest, one week. Three cases had convulsions. Two of
the patients complained much of headache, which in one of
them was very severe. Two were delirious ; but could be
roused to give logical answers. There was severe opis-
thotonos in one, slight in two. Tenderness at nucha was
found in two. The pulse was hard and full in the patient
aged 60 years, giving about 90 beats per minute. The pulse
was generally feeble, and quick. There was usually not
much pain in the bowels, which were generally constipated ;
the evacuations " showing a want of healthy bile." There
was retention of urine in one case. In one case only were
there petechias. They were upon the chest. In the child of
4 years there was great hyperesthesia of the surface. The
slightest touch would make it cry out, and bring on severe
opisthotonos and spasms. It did not recover its speech for
five weeks from the commencement of convalescence.

The treatment was " sometimes tonic and stimulant ; at
others sedative, with dry cupping and blisters."

Three of the patients recovered, and one died. There was
no autopsy.

The following case was sent to us May 26th, 1866, by
P. L. B. Stickney, M.D., of Chicopee, Mass.

" The history of the case is peculiar. The patient was
an unmarried girl aged 30 years, and who on a visit to Brook-
lyn, Xew York, was made the victim of a fraud practised
upon her by an unprincipled physician, who in order to cure

APPENDIX. 141

her of a 'uterine difficulty/ as he termed it, she not being
well, committed upon her a rape, as so decided by the Court
of that State, and was accordingly punished. She became
pregnant, and at term was delivered with instruments after a
protracted and severe labor. Convalescence was slow, and
she was still weak, when six months after the delivery she
attended the Court at Brooklyn, at the trial of the physician.
She took a severe cold, and on returning home was taken
sick, Dec. 21, 1865. The case proved to be meningitis. The
disease commenced with most violent pain in the head, over
the eyes, extending to the top of the head, and finally to the
back portion, and proceeding down the spine. This pain
was most excruciating, causing the patient to shriek and
scream violently. The patient soon became delirious, and
spasms of the upper and lower extremities followed. The
head was drawn back, with rigidity of the muscles of the
body. There was no great degree of heat of the body ; the
pulse rose to 110 to 115 ; respiration proportionally quick-
ened. The tongue was red around the edges, with a yellow-
ish fur in the middle ; the thirst quite considerable ; the eyes
staring, the sclerotica tinged, and slightly yellow, as also
the skin of the body. At intervals the pain in the head and
back would slightly abate, and the delirium would pass off,
but would again recur on the return of the pain. There
was nausea, with tendency to vomiting.

" The treatment was first an active purge of calomel com-
bined with opium, followed by black draught, sinapisms to
the spine, cold upon the head. The action of the cathartic
produced a large discharge of black fetid fasces, accompa-
nied with a copious urinary discharge. In order to quiet the
pain and' allay the spasmodic tendency, full doses of morphine
were administered, and counter-irritation applied to the spine.
This was the treatment for the first few days. No abatement
of the symptoms, excepting less delirium. On the third
day pain less in the head ; less in the cervical, but more in the
dorsal and lumbar portion of the spine, proceeding down the
lower limbs, causing them to contract spasmodically. The
pain also extended around the hips, through the bowels, and
left side. There it was excruciating. The patient was
obliged to lie on the right side, with the knees drawn up.
She moaned bitterly. Pulse 110. Skin inclined to be cool
and moist. Thirst slight, tongue dry and furred, edges
looking red.

" Treatment. Small doses of calomel and opium, with full
doses of morphine at intervals to allay the intense pain and

142 APPENDIX.

procure sleep : counter-irritation to the spine ; hot fomenta-
tions on the side and bowels. On the fourth day the spots
appeared upon the face, chest and upper part of the body.
Pain more or less severe in the head and throughout the
whole length of spine. The skin became very sensitive, and
patient complained of prickling sensations, declaring that
"worms were crawling over her." Could not bear the
weight of the bed-clothes : continued to lie with the legs
drawn up. and on the right side ; very sensitive to the light
and to sound, and could not endure the smell of the cooking
arising from the kitchen. In tine, all the senses were ex-
quisitely acute and sensitive. The bowels were again mov-
ed, the evacuations now yellow and less offensive. Urine
somewhat scanty and high colored. Skin cool, some perspi-
ration : pulse 95. As the bowels had been well moved, the
calomel was discontinued, and as the morphine had failed to
induce sleep or to allay the spasmodic tendency. I gave the
tinct. Cannabis Indica. in 15 drop doses every four hours.
The diet during this time was light, but nutritious. The pain
was peculiar in its course. It would commence in the head.
pass down the spine, thence around the side and bowels,
producing the most intense agony, then suddenly leaving,
run rapidly down the course of the sciatic or femoral nerve,
and attack the heel or top of the foot, remaining awhile,
then going over to the other foot, then up the leg, then up
to the head — hopping about here and there all over the
body. It was most piercing and violent, like neuralgia. At
intervals, when the pain was less violent, the patient would
sink into a state of stupor, the muscles of the throat and
mouth become rigid, the jaws closed and firmly pressed to-
gether, the breathing slow and at last hardly perceptible.
This state would continue for one or two i and once or twice
it continued three') hours, when suddenly the patient would
rouse up. look about, perhaps call for something to drink, and
say she felt better. This would continue a short time, when
the pain would come on, and the same exhibition of symp-
toms would take place. This stupor was not the effect of
the Cannabis or morphine, for it came on all the same whether
it was given or omitted. The action of the Cannabis seemed
simply to control the pain and spasm. This treatment was
followed up with cold and counter-irritation applied to the
spine, and the patient gradually improved. At the end of
three weeks she had so far recovered as to sit up long enough
tc have her bed changed. One day i Jan. 15. 1866 . however,
contrary to directions, she was induced, by the injudicious

APPENDIX. 143

advice of her friends, to have her clothes put on, and to
' move about a little, and thus get strength faster/ The
consequence was that the ' getting up ' was overdone and
the patient undone. A relapse followed ; all the symptoms
returned with redoubled fury. The pain was excessive, and
not only affected the head and spine, but every organ in the
body. The skin and the sclerotic coat of the eye became of
a dark yellow ; the urine was almost black, and passed with
the greatest suffering ; great and constant nausea, with occa-
sional vomiting of a dark colored fluid, set in.

"The pain in the bowels was intense, especially in the
region of the bladder. The menses made their appearance,
copious and very dark in color. Pain in head and back was
less violent, but more in the side and bowels. The skin
was inclined to be cold ; pulse 78 ; appetite gone ; tongue
quite clean. Treatment — Cannabis continued, with quinine
one to two grains every four hours ; brandy, beef tea, &c.
Cold was applied to the spine.

" The state of stupor became more prolonged, the strength
holding out remarkably. Iron and the whole tonic and stimu-
lating treatment was thoroughly carried out. This continued
about a week, when the pain in the pelvic region became in-
tense, the patient complaining of a weight, a ' bearing down.7
A vaginal examination revealed nothing. No pain of the
neck and substance of the womb and bladder, and yet the
pain on passing water would cause the patient to cry out in
agony. The bowels were moved in the mean time, produc-
ing copious dejections of dark-colored faeces. This state of
things continued till the 20th day of February. The Canna-
bis had lost its power, and the different forms of narcotics
were tried in succession. Different applications to the spine
were used. Ergot was not tried, as I had seen it used in
another case with not the least good effect whatever. The
different alkaloids, strychnia, veratrine, &c. were all tried,
and, so far as I could judge, not the least benefit was derived
from anything of the kind. At this period the pain suddenly
left the pelvic region, and attacked the chest and stomach
with the same degree of violence. Pain in the head very
much less ; in the spine, about the same. Up to this time the
patient had taken considerable food. Beef tea, gruel, toast,
anything which she would eat, that was nutritious, was allow-
ed. Now, Feb. 25th, commenced the exhibition of a differ-
ent series of symptoms. Nausea commenced ; pain in the
stomach and chest increased ; strength began to fail. Suffer-
ings at times intense ; stupor more frequent ; finally vomiting

APPENDIX.

commenced. Skin of a deep, dark yellow ; petechise here
and there ; urine dark brown, thick ; extremities feeling
numb and cold ; pulse 10 ; tongue clean. The peculiar sen-
sitiveness of the body gone. Could bear light and sound, but
the sense of smell very acute ; cannot bear any smell of food,
intense loathing of it. Pain in the chest and stomach in-
tense. The fluid vomited was of a dark brown color, at times
black, resembling, I should judge, that which is vomited in
yellow fever. Nothing had the least effect in stopping this
vomiting. Counter-irritation over the stomach, local appli-
cation of any kind, seemed rather to increase it. Anything
taken into the stomach would induce it. Its very presence
in, passing down the throat would bring it on. This vomit-
ing continued for twenty-seven days, and during that time not
a particle of food was retained on the stomach. During this
time she would occasionally take a little warm gruel to ena-
ble her to vomit the more easily, but it would seem to be all
returned. In order to allay the pain, and as all kinds of
medicine taken by the mouth only aggravated the vomiting,
I allowed her to inhale a few drops of chloroform. This gave
her the only relief she got. While under its influence she
would lie quietly, but as soon as it had passed away she
would most piteously beg for more. At the end of the 14th
of March she began to vomit a thick grumous substance,
which on examination proved to be blood. In the course of
two or three days the hsematemesis was fully established,
and at times she would vomit a pint or more of dark clotted
blood, and at one time the nurse, a very intelligent person,
estimated it to be not less than a quart. At this time nothing
was retained on the stomach, and the idea of taking either
food or medicine or any outward application, would induce
the vomiting. Only the chloroform gave any relief. I tried
nit. argenti with belladonna, also the sub-sulphite of soda ;
in fine, everything which seemed likely to do good, but with-
out avail. The mind at this time was remarkably clear and
composed. No delirium, and the turns of stupor less fre-
quent. About ten days before she died, blood began to ooze
from the gums and lips, and finally from the chin and at the
junction of the alse of the nose and cheek, also from the
forehead. It came also from the tips of the fingers of one of
the hands. Dark purple spots appeared upon the body, and
there seemed to be a purpuric condition of the whole system.
She gradually sank, and death closed the scene of suffering,
March 24th, 1866, the patient having been sick ninety-three
days." * * *

APPENDIX. 145

By a misunderstanding on -the part of the friends of the
patient, Dr. Stickney lost the opportunity of making a post-
mortem examination.

" The pathology and treatment of the malady, says Dr.
Stickney, ' seem to me not as yet to be understood. I have
seen some phases of it, I think, in a modified form, and in
connection with the exhibition of other forms of disease, of
which I can give myself no intelligent response, unless this
disease is either at the bottom or in some obscure manner
connected with them.' "

The following cases are from the Records of the Boston
Society for Medical Improvement (for 1866).

May 28th. — Cerebrospinal Meningitis. — Dr. Morland re-
ported the case, the following account of which is prepared
from the record furnished by Dr. J. F. A. Adams, resident
graduate in the Medical Department of the City Hospital.

G-. W. T., twenty-eight years old, was admitted into the
Boston City Hospital, May 24th, 1866, at 3 o'clock, P.M.
He was at once seen and prescribed for by Dr. Adams. Very
little of his previous history could be obtained. A friend,
who came with him, stated that he was unmarried, and that,
since he had known him — about two years — he had not been
very strong, but that he was a quiet, temperate man. He
was a dealer in photographs, and a resident of Boston. His
father and a brother, it was stated, died of phthisis.

He was taken ill on May 20th, and is said to have been in
a state of stupor during the first few days. Dr. George Der-
by, Admitting Physician to the Hospital, on first seeing him,
supposed him to be intoxicated, but immediately discovering
him to be very ill, sent him at once to the Hospital. On ad-
mission, he was almost completely unconscious, groaning and
crying, as if in great pain, which, so far as could be ascer-
tained, was in the head, and especially on the left side, and
over the upper part of the forehead, upon which he constantly
kept his hand. When aroused and asked if he felt pain else-
where, he replied that he " did not know of any." The pupils
were contracted, the pulse 68, very full, hard, and irregular.
He was exceedingly restless. A slight sero-purulent, dark-
colored discharge from the right ear was noticed. A sina-
pism was applied to the back of the neck, and a scruple of the

146 APPENDIX.

bromide of potassium was administered. At 7 O'clock, P.M.,
large sinapisms were applied to the calves of the legs, and
the dose of bromide was repeated, and continued, every two
hours, through the night. During- the evening, six leeches
were applied behind each ear, and the bleeding was very free
after their removal. The urine was drawn off by the cathe-
ter, and was of a very dark, coffee color. The pulse rose to
one hundred after the leeching, and became softer and more
regular, but was still very variable. The pupils were then
observed to be dilated, and they remained so. A few dark-
colored, minute spots, not fading on pressure, were observed
upon the chest.

The patient was seen by Dr. Borland about 10 o'clock next
Q] "._-. May 25th. The pulse was then 120, and exceed-
ingly small and weak : there was some sordes upon the teeth :
the spots upon the chest were the same. The bowels had
not moved since admission. A warm salt-and-water enema
was directed : also an ice-bag to the head, and wine and
water, freely. The patient was exhausted, and very restless
during the entire day. crying and moaning, as if in pain, and
quite unconscious. The enema produced a free evacuation of
dark-colored faecal matters. The urine passed involuntarily.
Gruel was swallowed without much difficulty. In the after-
noon, the pulse was weaker and exceedingly irregular — vary-
ing from 80 to 160, within a few minutes, and almost without
rhythm. A vapor-bath was used, in bed, and a tolerably free
diaphoresis was obtained. The patient became more quiet
after the bath, and the pulse was 152, full, soft and regular.
The relief, however, was only temporary, and he continued
in his previous condition, with the exception of increasing-
weakness, until 4 o'clock the next morning, when he died,
about 37 hours after admission.

The nurse stated that she had observed convulsions, of
short duration, but it could not be positively determined
whether these were any thing more than the violent jactita-
tions which were constantly present. There was certainly
no opisthotonos.

On examination of the urine, albumen was found to be
abundant, and the microscope revealed granular casts and
pus-ceUs. Urea could not be detected.

Ill reference to the diagnosis, it was not easy to make a de-
cision. Typhoid fever was suggested by the stupor, the
sordes and the general condition. The spots upon the chest
were not '•'rose-spots,'" nor were they of a purpuric nature.
The somewhat dubious report as to the occurrence of convul-

APPENDIX. 147

sions, in connection with the results of the examination of
the urine, suggested uraemia. It is fair to add, that, although
cerebro-spinal meningitis was mentioned, in this connection,
no positive diagnosis was made. The account of the post-
mortem examination, which was made by Dr. C. W. Swan,
Pathologist to the Hospital, is appended. The specimen was
shown to the Society by Dr. Swan.

Autopsy. — May 27th, 9 A.M. — Membranes of the brain
rather dry. A sub-arachnoid deposit of opaque, yellowish
fibrin over the upper and anterior parts of each hemisphere,
particularly towards the median line— at the base of the
brain, extending into the various fissures, and upon the supe-
rior and cuneiform process of the cerebellum.

The whole length of the spinal cord was enveloped in a
similar deposit, which was, however, less in amount towards
the upper extremity than elsewhere. Lungs pale, healthy.
Liver and kidneys rather dark. The stomach was distended
with gases, and contained bright, olive-green fluid in large
quantity. The heart was firm. Fibrinous coagula in both
sides. Right auricle and vena cava distended by soft black
coagula. About half an ounce of serum in the pericardium.

Dr. II. K. Oliver said he saw this patient previous to his
application for admission to the City Hospital. The first day
of his illness great complaint was made of pain in one of the
ears, the membrana tympani of which was much congested :
the next day there was a great discharge of pus with a little
blood from the same ear ; there were then no symptoms of
meningitis.

Dr. Jackson suggested that in this case the inflammation
might have extended from the ear to the membranes of the
brain. He said this might take place though the bone inter-
vening was perfectly healthy, and instanced several cases of
the kind which had come under his observation.

Dr. Oliver said the same idea had occurred to him.

June 11th. — Cerebrospinal Meningitis ) Death] Autopsy. —
£)r. Blake reported the case.

Miss L. R., 26 years old, was admitted to the City Hospital
June 2d. For a year has had otorrhoea, with deafness, for
which she has been treated by an irregular practitioner, by
means of injections, &c, without relief. Five days ago, the
present trouble commenced, with headache, confusion of
thought, and a feeling of general malaise. Two days after,
she was obliged to keep her room, had pain in her back,
weakness of knees, and a good deal of febrile action. Was

148 APPENDIX.

seen by a physician, who, after an examination of her case,
thought her symptoms indicated commencing varioloid. Dur-
ing the evening of this day, she first noticed pain and stiffness
of the posterior cervical muscles, and shortly afterwards was
seized with severe cephalalgia, loss of consciousness to some
degree, slight strabismus and opisthotonos, and had remain-
ed in that condition up to the time of entrance.

On admission, the opisthotonos was found very well mark-
ed— head thrown back, body arched, legs stiff, &c. — almost
wholly unconscious ; mouth partly open, and lips covered
with little herpetic vesicles ; eyes half closed, with moderately
dilated and sensitive pupils ; respiration labored and noisy,
32 ; pulse 120, regular ; tongue dry and brownish ; sordes
on teeth. A number of dark, purplish-looking spots, one
eighth of an inch in diameter, noticed on chest, neck and
arms ; spots not raised, do not disappear on pressure.

Leeches behind ears, ice to head, and bromide of potassium,
in large doses, were prescribed. Liquid nourishment by
rectum, if unable to swallow. Next day, the opisthotonos
had disappeared, but the cervical muscles continued rigid ;
she could swallow liquids without much difficulty ; pulse had
come down to 90 ; pupils somewhat dilated and sensitive ;
still unconscious ; faeces and urine passed involuntarily.

The following day she was in about the same state — respi-
ration and pulse a little quickened ; rigidity of muscles as
marked ; no return of consciousness. Next day she died.
The following is the report of the post-mortem examination,
as made by Dr. Swan.

Examination, 10 hours after Death. — Head. The large ves-
sels of the pia mater, on the upper surfaces of both hemi-
spheres, particularly about the vertex, were turgid with
blood, and the minute vessels lying on the convolutions were
unusually distinct. There was a sub-arachnoid deposit of
soft, greenish-yellow lymph in many places on the upper sur-
faces of the hemispheres, at and between their anterior ex-
tremities, in the fissures of Silvius, at the optic commissure,
on the pons Varolii at the anterior edge of the cerebellum,
and on its superior vermiform process. Lying free upon that
portion of the dura mater which covers the upper surface of
the right hemisphere, was a continuous, uniform layer of
lymph two or three square inches in extent. A less amount,
in small, scattered particles, occurred upon corresponding
portions of the left side. There was no excess of fluid in the
serous cavities of the brain or cord : the brain-substance was
firm ; the puncta cruenta large.

APPENDIX. 149

Beginning five inches from the upper extremity of the
spinal cord and extending downward about seven inches,
was a thick, unbroken deposit of soft, pale, greenish yellow
lymph. It was entirely confined to the anterior aspect. On
the posterior surface, the minute vessels seemed slightly in-
jected, but there was no trace of lymph.

^ In the left pleural cavity, ten ounces of a turbid brownish
liquid, sustaining fat globules on its surface. The two prin-
cipal pulmonary veins of the left lung, and the left primary
and two secondary bronchi, were laid bare to the extent of
one or two inches, and several venous branchlets were com-
pletely isolated for an inch, more or less, by a curious super-
ficial progressive waste of the parenchyma of the lung. This
process was most marked on the inner surface of the lower
lobe, but it had invaded a portion of the upper lobe nearest
its roots and had also extended between the two lobes. It
had destroyed at least the pulmonary pleura in its course,
the line of demarkation being in general easily made out, but
there was also undoubted loss of proper lung tissue towards
the centre of the diseased action, although the finger found
no deep cavities. The bare parenchyma presented a rather
smooth, lobulated surface of a deep brown color. There was
little or no odor about the parts. The posterior and upper
surface of the lower lobe showed small hemorrhagic blotches
beneath the pleura. Section showed considerable lobular
pneumonia. The same disease, to less extent, existed in the
right lower lobe. Rest of lungs healthy. Other organs
normal.

In addition to the few cases given above as having occurred
in 1866, we have seen it stated that " spotted fever 7; invaded,
during the early part of the present year, the Seminary in
Pittsfield, which suffered from an endemic of typhoid fever a
few years since. Of the cases in this recent invasion of
Pittsfield we have not been so fortunate as to obtain details.

Of course we have not sufficient data to enable us to say
whether or not " spotted fever or cerebro-spinal meningitis •"
continues to prevail as an epidemic in this State.

150 APPENDIX.

Doubt has been entertained as to the true nature of the
endemic denominated "typhoid" in the preceding para-
graph, and mentioned as occurring at the Seminary in Pitts-
field. That endemic is the one referred to by Dr. C. E. Ware
under the head of " Contagion," in table E.

PUBLICATIONS

OF THE

MASSACHUSETTS MEDICAL SOCIETY.

VOL. II. — N°- II.

IJisiorg of Inoculation in lltassatjntsetfs,

BY J. M. TONER, M.D.

OF WASHINGTON, D. C.

Casts of Cricjmta Spiralis in Springfield

BY M. CALKINS, M.D.

OF SPRINGFIELD.

%\t fmw> of \\t Whx lo % Steal

BY GEORGE DERBY, M.D.

OF BOSTON.

Cjje |atjjoIogir aito treatment of Paginal

BY JOHN HOMANS, Jk., M.D.

OF BOSTON.

BOSTON:

PRINTED BY DAVID CLAPP & SON 334 WASHINGTON ST.

MEDICAL AND SURGICAL JOCRNAL OFFICE.

186?.

HISTOEY OF

INOCULATION IN MASSACHUSETTS.

By J. M. TONER, M.D.

OF WASHINGTON, D. C.

The following chapters on Inoculation contain that portion of the
general history of Inoculation for the smallpox in America which relates
particularly to Massachusetts. This portion is taken from its place in a
prepared but unpublished " History of Inoculation in America," and is
offered to the Massachusetts Medical Society for publication in their
Transactions, by

The Author.

CHAPTER I.

American Colonies — Rev. Cotton Mather — Royal Society's Transactions-
Smallpox epidemic in Boston — Inoculation suggested — Great opposition to
Dr. Z. Boylston, the first inoculator — Rev. Cotton Mather — Rev. Increase
Mather — Their great influence — Sketch of Dr. Boylston — His first inocula-
tions— Numerous cases follow — Old and new styles — Results of inoculation —
Statistics of the casual disease — Great distress among the poor — Mortality of
the casual and inoculated disease — Mode of operating changed — Opposition
to the- practice — Dr. Boylston's character.

While Inoculation was slowly fighting its way to favor
in England, and achieving a victory for the whole continent,
events of equal interest were transpiring in the American
colonies. Boston, then the chief commercial emporium of
the new world, had a population of some 12,000 inhabi-
tants, who were already distinguished for their intelligence
and thrift. But the pulsations of trade and enterprise
which throbbed through Boston from the great heart of
London were feeble, though healthy. Communication with
the old world was slow and infrequent, and the excitement
and sensations of the populous cities of Europe were not
felt in the colonies till long after they had expended their
force, if indeed they were felt here at all. Hence it was
that while the people in America were yet ignorant of the
inoculation movement in England, they were engaged in
making very similar experiments, but on a much more exten-
sive scale.

It seems to be -quite clear that the commencement of the
practice in Boston was not at all dependent on events which
had taken place in England. The published papers of the
Royal Society found their way naturally enough to the more
intelligent circles on this continent, and the letters of
Timoni and Pylorini, published in 1 714-15, upon the subject
of inoculation as practised in Turkey, were regarded as so

154 INOCULATION IN MASSACHUSETTS.

curious that Dr. Douglas, who was in receipt of copies,
called the attention of the Rev. Cotton Mather to them, and
lent him the numbers of the " Transactions " in which they
were published. (See Note 1.) Mather was then a young
man just rising into notoriety, and the idea of mastering
smallpox by the novel practice of the Byzantine inoculation,
seized hold of his earnest nature in a way not to be shaken
off; and shortly after there was a concurrence of circum-
stances eminently calculated to call into practical service the
faith which the articles alluded to had inspired.

It will be remembered that the first inoculation in England
was that of Lady Mary "Wortley Montague's daughter, which
took place in April, 1721. During the same month, and
while the young and noble patient was yet under the effects
of the disease thus artificially induced, some vessels arrived
in Boston from Saltortuga, with smallpox on board (Note 2),
whence it was communicated to the people of the town, and
raged for many months, causing the most fearful mortality.

But it was not a new or a strange visitant. (Note 3.) It
had been there before ; and although it was nineteen years
since (Note 4) it had prevailed as an epidemic, the old inha-
bitants retained a vivid recollection of its ravages, which had
not been confined alone to the European settlers, but extend-
ed to the Indians, among whom it was even more destructive
to life than among the white population.

As soon as the smallpox appeared as a decided epidemic
in Boston, the Rev. Cotton Mather, fresh from his reading of
Timoni and Pylorini, was very earnest . for making instant
trial of the Turkish remedy, confidently hoping by this
means to protect the people against the severity qf the
disease. To this end he had made copies of the articles
on the subject in the Philosophical Transactions, and caused
them, accompanied by an urgent letter from himself in favor
of the practice, to be laid before every practising physician
in the town, thinking that they would at once seize on the
idea and put it into immediate practice.

INOCULATION IN MASSACHUSETTS. 155

But the " vain preacher/' as Dr. Douglas calls him, had
judged others too much by himself, so that, with a solitary ex-
ception, his good and timely advice fell upon perverse sensi-
bilities, and produced no favorable response. (Note 5.)

One physician alone of all the practitioners in Boston was
impressed with the fall importance of the proposed remedy,
and determined to give it a trial. This was Dr. Boylston
(Note 6), a man of fair ability and extensive experience in
his profession, who had suffered much in his own person
from smallpox, and witnessed its ravages nineteen years
before, when it swept off great numbers of his friends in
town and country. He possessed enlarged views of profes-
sional duty, great moral courage, and an experience with
the disease which enabled him to take heavy responsibilities.
He was encouraged the more to make trial of inoculation
from the impotency of all the remedies then known to the
profession, none of which could either control the severity
of the disease or give an encouraging promise of recovery.
He had for his personal friend the Rev. Cotton Mather
(Note 7), a zealous advocate of the practice, and who was
in a position to render him a powerful support.

Perhaps no name in the early history of New England is
more conspicuous than that of Cotton Mather. The son of
one of the most distinguished religious teachers in America,
generously endowed, well educated, of an active and vigorous
temperament and high moral organization, he was, besides,
a fluent and voluminous writer, a popular preacher, and not
at all disposed to shrink from any contest which circum-
stances might thrust upon him. He was the first upon this
side of the Atlantic to be favorably impressed with the idea
of inoculation as a remedy against the fearful ravages of the
casual smallpox, and was not only the , first but the ablest
and most efficient advocate of that innovation in America.
Indeed it was his zeal and energy which inaugurated the
movement, and, combined with his great influence, which

156 INOCULATION IN MASSACHUSETTS.

pushed it on to ultimate triumph. He was, however, gener-
ously sustained by his father, the Rev. Increase Mather (Note
8), then in the zenith of his strength and popularity, and by
so large a portion of the clergy (Note 9) that the newspaper
scribblers of the day turned the tables on them by repre-
senting that the contest so long waged about inoculation was
a matter of difference between them and the people.
(Note 10.)

The articles which Rev. Dr. Mather caused to be copied
from the Philosophical Transactions were distributed on the
6th of June, 1721, and on the 26th of the same month Dr.
Eoylston performed the first inoculation. (Note 11.) Like
Lady Mary Wortley Montague, he showed his strong faith
in the remedy by first trying it on his own son, and then on
two of his negro servants. The mildness of the disease by
inoculation, and the satisfactory termination of the cases,
gave him the assurance which he needed to justify a recom-
mendation of the practice to his patients, and, surprising as
it may seem, he actually inoculated, from the 26th of June,
1721, to the end of January, 1722; 244 persons. (Note 12.)

A letter to Dr. Jurin, Secretary of the Royal Society
from the Rev. Cotton Mather, bearing date March 10th,
1721, estimates that there had been inoculated in and around
Boston 300 cases, out of which five, or at most six, died.
Dr. Mather in his dates must have conformed to the old
style (Note 13), while most historians alluding to the event
used the new, for the disease, as we have noted, did not
appear in Boston until April, 1721, new style; March, ac-
cording to that computation, having already passed. These
inoculations were made on all sorts of persons, without that
discrimination in regard to the patient's habit of body, his
freedom from disease, or his advanced age, which a fuller
experience showed to be necessary. We need hardly say,
therefore, that where the disease was prevailing with such
malignancy there were some deaths. Of the 282 inoculations,

INOCULATION IN MASSACHUSETTS. 157

274 had the disease favorably, 6 were unaffected; and 6 were
supposed to have died of it. The first death was in the
latter part of September, a Mrs. Dixwell, aged 37, very fat,
and of a feeble constitution. She died on the seventeenth
day of the eruption. The second, John White, Esq., died
in December. He was of a weak and sickly constitution,
and died on the twelfth day of the eruption. An Indian
girl of 1 7 was the third fatal case. The fourth was Bethiah
Scarborough, a widow, of bad constitution, 67 years old;
she died before the pock came out. The fifth was a Mrs.
Wells, aged 54, a sickly, splenetic woman, and, as the doctor
observes, " often deprived of reason, and for many years not
capable of managing her affairs." She died on the ninth
day of the eruption, having suffered greatly from the cold
weather. Mrs. Serle, aged 61, was inoculated at the same
time, and was also a delicate, hysterical woman, and of an
ill habit of body. The disease was of a mild type, but after
the scabs fell off she was seized with an inflammation of the
bowels, and died on the twenty-foiirth day of the eruption.

Besides the 244 inoculations by Dr. Boylston set down in
the table, two others were performed by him after it was
printed off, and Drs. Roby and Thompson had inoculated
successfully 36 in Koxbury and Cambridge; so that the
whole number that acquired the disease was 2 76, .six remain-
ing unaffected. It thus appears that notwithstanding these
promiscuous and haphazard inoculations, made mostly as
experiments, certainly without experience, only one person in
forty-seven fell a sacrifice to the disease. But it was con-
tended by the friends of the practice, and with a probability
of truth, that at least two of the deaths resulted from causes
not connected with induced smallpox. The result was not
so flattering as had been hoped for by the more sanguine
friends of the measure, but it made, nevertheless, a much
better exhibit of the saving of life than that presented by
the Board of Selectmen in their report of casual cases after

158 INOCULATION IN MASSACHUSETTS.

carefully gathering the statistics of the disease, which for
nearly a year had been making sad havoc among the inhabi-
tants of Boston and its immediate vicinity.

From this report, a summary of which is preserved in the
Massachusetts Historical Collections, it appears that in and
about Boston, with its population of 12,000 souls, there
were 5,989 cases of smallpox, including the inoculations.
If we make allowance for the removal of families to other
places to avoid the contagion, this number must have con-
siderably exceeded one-half of the whole population liable
to the disease. Of these 5,989 cases, 844 died (Note 14),
which is one death in about every seven attacked, while in the
disease acquired by inoculation there was at most not more
than one death to forty-seven cases. (Note 15.)

During the entire prevalence of the disease many families
continued to reside out of town, and of those who remained
large numbers were protected by reason of having had
smallpox previously. In view of all the facts, the report
gives about 700 as the number of persons who, not having
had the disease, were proof against it, notwithstanding their
continued exposure to the contagion. From these figures it
would seem that the disease ran riot over the town, feasting
on all who were susceptible to its poison, and continuing its
ravages upon beauty and life so long as it had material to
feed upon, and subsiding at last simply because the supply
of victims was exhausted.

The comparative results between the mortality attending
the inoculated and the casual smallpox, as obtained by an
actual census, was not spread before the public until long
after the storm of violent opposition and blind passion had
subsided ; but it eventually formed the basis of a sound and
intelligent public opinion in favor of the practice of inocula-
tion, which ultimately grew into public favor.

It could not be otherwise than that there should have been
many instances of great destitution and suffering among the

INOCULATION IN MASSACHUSETTS. 159

poor for the want of the comforts and necessaries of life,
almost quarantined and cut off through fear from their ac-
customed country supplies during the prevalence of an epi-
demic of such unusual severity and duration as was that of
1721. The panic became so general as to arrest work on
public and private improvements, day laborers and mechanics
of all kinds were without employment, and consequently
their ordinary means of earning support were taken from
them. Business of all kinds was greatly interrupted or
actually suspended. From sickness and the suspension of
income, with the extraordinary expenses required, the well-
to-do were made poor, and the poor impoverished to the
last degree. But the destitute of Boston in their hour of
need were not neglected; they received sympathy and
generous succor both from their own corporation and from
surrounding places, as instanced by the prompt and liberal
contribution (Note 16) from the town of Scituate, Plymouth
County, Massachusetts, distant about twenty-eight miles from
Boston.

Inoculation was not permitted to go on smoothly, and to
accomplish even the small saving of life it did, without exhi-
bitions of the most passionate and violent opposition. Its
authors were persecuted, personally abused and insulted,
arraigned before the civil authorities, and held up to repro-
bation in the newspapers, and in every possible way made
to feel the wrath of an offended community. But much
valuable experience had been gained, and many important
facts collected bearing upon the amelioration of the suffering
from this disease, which were published and made a strong
impression upon the public mind. Formerly there had been
no security but in flight, but the inoculation movement
awakened in the hearts of the people a hope that medical
science, under Providence, might devise some means of miti-
gating its severity. At first Dr. Boylston performed the
operation according to the mode described by Timoni; but
21

160 INOCULATION IN MASSACHUSETTS.

so bold an experimenter could not long be confined to a
practice so cumbrous and unprofessional. He says : i( The
Turkey mode of scarifying and applying the nut shell, &c,
I soon left off, and made an incision through the true skin
and applied the plaster over it, which I have found since to
be the better way."

He also dropped the practice of inoculating in several
different parts of the body. The prolonged illness and ulti-
mate death of the few who died of smallpox acquired by
inoculation taught also a lesson, and the greater caution,
with the more careful discrimination of suitable subjects,
secured more fortunate results in after practice. Dr. Boyls-
ton, by his close observation, discovered the important fact
that smallpox taken by inoculation will develope itself four
or five days earlier than when the disease is taken by conta-
gion in the casual way, and may therefore be made to super-
sede the latter and divest it of some of its dangers. The
discovery of this important law in the development of the
disease has been claimed by others, but is justly due to our
American inoculator. (Note 17.)

But the New England operators eventually fell into the
same error which the profession of Europe did, of making
large and deep incisions so as to secure a plentiful discharge
of matter. This was done in consequence of the humoral
pathology controlling largely the opinions of the profession
in this country as well as in Europe. This cruel mode
caused much unnecessary suffering and generally retarded
recoveries, and not unfrequently entailed permanent lame-
ness.

Inoculation in the colonies, as also in Great Britain, did
not triumph at once, but had to fight its way little by little
through more or less opposition for many years. But the
battle which decided the fate of the new remedy in America
was fought over the inoculation of 1721 by Dr. Boylston.

How severe that contest was, we will endeavor to show in

INOCULATION IN MASSACHUSETTS. 161

the next chapter. Meantime we pause a moment to express
our admiration for the man whose faith in his own skill and
ability to relieve human suffering was stronger than his fear
of opprobrium or persecution, and who, amid public and
private censure, adverse official action, and professional op-
position, continued his philanthropic work, and in the face
of the severest discouragements pushed forward with confi-
dence in his experimental cases until he had accumulated a
store of facts which fully vindicated his judgment and called
down upon his head the blessings of his countrymen.

In England inoculation was introduced at first among the
most elevated in society. Accidental circumstances soon
took it thejice into the court circle, the King giving it his
royal sanction. But notwithstanding these great advantages,
the profession did not advance to an enthusiastic advocacy
of it, but were rather led forward in the matter by the
people. Even the first operators there were timorous and
hesitating to a remarkable degree.

The idea that it was borrowed from the lazzaroni stag-
gered and dampened their ardor, and they did not put into
their advocacy enough enthusiasm to carry it with any mo-
mentum into the stolid ranks of a conservative public
opinion. The conduct of Dr. Boylston contrasts admirably
with this temporizing spirit. He threw himself into his
work with the earnestness and zeal of a man who had faith ;
and while the English doctors were halting and trying ex-
periments on condemned convicts and the children of charity
schools, he recommended the practice to the whole circle of
his friends. He also sealed his faith in the remedy by
applying it to his own family, and in a short time gave to
the world the record of the recovery of two hundred and
eighty-two cases, with facts and figures which stamped it a
successful mode of practice in combating the mortality of
the casual smallpox on this continent.

CHAPTER II.

Friends of inoculation in Boston — Great opposition to the measure — The Doc-
tors generally oppose it — Malevolence of the opposition — Dr. Boylston perse-
veres— Controversies — The practice conducted secretly— Attempt to destroy
Dr. Mather's house — Dr. Boylston brought before the authorities — Contro-
versy of the clergy with Franklin— Dr. Douglas and his hostility — The
Selectmen also interfere — Violence against Dr. Boylston attempted— His
escape — The practice gains confidence.

In looking back on the efforts of Rev. Cotton Mather to
enlist the medical profession of Boston in behalf of inocu-
lation; his course will generally be regarded as prudent and
wise, and well calculated to attain the end which he had
in view. If the doctors had consented and acted in concert
in giving the new remedy a fair trial, it is easy to see that
they would have so strengthened the moral influence of each
other, and so affected the sentiment of the community, that
the few unfortunate cases which had occurred would not have
poisoned the public mind or aroused the popular prejudice
against the measure. And at the same time the independent
but harmonious action of the different practitioners in their
various circles and under diverse circumstances would have
soon furnished evidence of the best modes of inoculation
and after-treatment, and given an amount of practical expe-
rience which would have inspired confidence and almost
disarmed opposition, abridged the period of trial, and has-
tened the day of triumph, to say nothing of the hundreds of
lives that it would have saved.

But, on the other hand, the effort to harmonize the prac-
tice having failed, it greatly aggravated the difficulties of
any one who might venture to make the experiment. The
step taken in this direction by Dr. Boylston naturally enough
caused the rest of the profession to look upon him as a dis-

INOCULATION IN MASSACHUSETTS. 163

senter, as his action in the matter was a standing censure
upon their hesitation or want of judgment. They had vir-
tually rejected the Turkish remedy; he had accepted it.
Their conduct implied want of confidence in it; his
implied the utmost faith. They had stood aloof; he had
advanced and embraced it. Hence professional jealousies
were aroused, and there was a general desire that the expe-
riment might fail in his hands. This feeling strengthened
among the doctors as he boldly multiplied his cases/ and the
feeling was soon communicated to others, and finally spread
among the masses, and seemed to take possession for the
time of the great popular mind. It was most fortunate,
therefore, in view of this state of feeling, that no death
occurred among those inoculated till three months of expe-
rience had shown how generally mild and safe the inoculated
disease was.

A spirit of bitter opposition to the new practice was mani-
fested from the first inoculation, and it was very evident that
the doctors were not indifferent spectators of passing events.
Society was so excited and alarmed by the presence of a
loathsome disease in its midst, that, although ready to fly to
almost any remedy which promised even a moderate chance
of protection, it was nevertheless so undecided by the various
rumors, doubts and fears circulating that it required the
strong personal influence of Dr. Boylston and his compeers
to persuade persons to submit to inoculation. Doubts were
raised respecting its safety, its genuineness, its power of
protection against future attack, and especially as to the pro-
priety of inducing by artificial means a disease which was
already so fearfully widespread and destructive to life, and
when it was found that a death had actually resulted from
inoculation, the opposition broke out into a systematic de-
nunciation of the practice and a vigorous persecution of its
advocates. The friends of the Byzantine practice were
squibbed in the newspapers, insulted in the streets, subjected

164 INOCULATION IN MASSACHUSETTS.

to personal abuse, and made to feel in every way that they
had outraged the feelings and wishes of the community.

But the Mathers were strong in the confidence of the
public, and they did not falter in their support of the
measure for a moment. Most of the clergy were with them
in their approval, and became a powerful shield to Dr. Boyls-
ton, who persevered in the practice, with an unwavering
faith in its utility and general safety, in the very face of this
aroused" and maddened public sentiment. To make matters
worse, James Franklin, just prior to this, had started his
" Courant " in opposition to the " News Letter." The latter
was a weekly paper, patronized by the merchants, clergy
and the more respectable classes, while the former was left,
naturally enough, to gather around it those who had at one
time and another been repelled from this select circle, and
among the rest were the doctors who felt Dr. Boylston's
course to be a severe reflection upon them, and who were
consequently chagrined at the apparent success which was
following his novel innovation. The controversy, therefore,
not only got into the newspapers, but took a sharp, acrimo-
nious, and personal turn, so that the new remedy and its
friends formed for a time the leading topic of popular ex-
citement for the press. The "Courant" made it a point
to attack any and everything that was of consequence enough
to make a sensation, and on this subject had the popular
approval, though it was in bad repute with the officers of
the crown, and was finally suppressed by the strong hand of
the Governor. The clergy of course came in at an early
period for a share of its abuse, and on the 28th of August
a correspondent of the " News Letter," understood to be one
of the Mathers, gave it a very uncomplimentary notice,
which is significant, in this connection, chiefly on account of
its allusions to the doctors. (See Note 18.)

The disposition of the " flagitious and wicked " " Courant,"
as it was called in the " News Letter," was not at all soften-

INOCULATION IN MASSACHUSETTS. 165

ed towards the clergy by this attempt to lower its character
through the columns of the rival paper, and the Mathers
were attacked by name and unmercifully squibbed and ridi-
culed for a period of many weeks, mainly on the ground of
their defence of inoculation. And when, in the latter part
of September, 1721, the first death occurred among the
inoculated, the writers in the " Courant " turned all their
batteries of wit and sarcasm against the advocates of the
practice, not only annoying them individually, but greatly
stimulating and maddening public sentiment against them,
already exasperated to a point little . short of outrage and
summary vengeance.

One of the fruits of this exasperated state of feeling was
an order passed at a town meeting (Note 19) held on the
4th of November, prohibiting any person from coming to
Boston to be inoculated, and providing that all inoculated
persons should be removed to the pest house.

This order put the inoculators on their guard, and much
of the work had to be done in a quiet or secret manner.
Rev. Mr. Walter, the minister at Roxbury, who was a nephew
of Dr. Cotton Mather, came over to Boston and was inocu-
lated at the Rev. Dr.'s house, where he remained to be cared
for during his sickness. By some means this fact got to be
known beyond the family circle, and some malicious person,
who may have had private griefs to revenge, in addition to
the violation of the order upon the subject of inoculation,
made this pretext, and having prepared himself with a gre-
nade shell filled with explosive materials, and armed with a
lighted fuze so arranged as to set it off at the proper mo-
ment, came to the house about three o'clock in the morning
and threw it into the chamber where the reverend patient
was lodged. (Note 20.) This was some ten days after the
order of the town meeting; and while it shows that the
public feeling was greatly exasperated, it also shows that
the authorities, who must have known of the inoculation of

166 INOCULATION IN MASSACHUSETTS.

Rev. Mr. Walter, took no care to encroach on the privacy of
the Rev. Cotton Mather, or to put the order in force against
his kinsman. Fortunately for the lives of the inmates of
the house, and for the peace of the community, the fuze was
knocked out in falling on the floor, and the terrible engine
of destruction failed to explode.*

But while the opposing elements were very violent among
the ignorant, and the poor and needy members of society,
there soon began to be a noticeable hesitancy in the more
intelligent circles, probably arising from a shadowy convic-
tion that after all their prejudice against inoculation it might
prove to be a practice worthy of serious attention. Dr.
Boylston was everywhere known as the professional head
and leader of the offensive practice, and was several times
brought up before official bodies and examined as to the
facts which were being developed in his practice. But these
examinations, instead of being an injury to the cause, were
possibly in the end an advantage. The calumnies which he
was thus enabled to refute, and the facts and results to which
he pointed in verification of his assertions, were all strongly
in favor of inoculation, and though not fully believed, his
candor and willingness for an open investigation were shown
by the repeated invitations he extended to the profession
and the authorities to visit his patients and judge for them-
selves. Although these invitations were never accepted, yet
their effect was not entirely lost upon the authorities.

The Selectmen of Boston, an official body analogous to
the "Supervisors" of New York, or the "chosen freehold-
ers" of some other States, as the guardians of the people,
thought it their duty to meddle largely in the matter of inocu-
lation, and seem to have acted pretty uniformly against the
practice. Among their absurd acts of bias and prejudice
was the publication of an affidavit made by Dr. Dalhonde^

* See Hutchinson's History of Massachusetts Bay, yol. 2, p. 275.

•

INOCULATION IN MASSACHUSETTS. 167

formerly a surgeon in the French army, who had travelled
largely and was particularly bitter against the inoculators.
His plausible story was well calculated to destroy all confi-
dence in the new remedy. The doctors opposing the practice
seem to have induced him to make a statement on oath of
his personal experience with the practice, before two magis-
trates, and then they adroitly got the Selectmen to assume
the responsibility and take the odium of making it public.
This appears from the certificate of Dr. Douglas, who, in
giving the translation, says :

"Boston, July 22, 1721. The foregoing is a true trans-
lation from the declaration made in French, by Dr. Dalhonde,
done at the instance and request of the Selectmen of the town of
Boston."

The certificate of genuineness is signed, as witnesses, by
William Douglas and Jas. Marion ; also by the Justices of
the Peace, Tim. Clark and W. Wellstead.

It will be observed that the date of this affidavit is nearly
one month after Dr. Boylston began his inoculations. The
Selectmen immediately published the document as a true
statement, circulating it extensively throughout New England,
and sent many copies to Great Britain, where it was re-pub-
lished, to prejudice opinion there against the practice. Al-
though the truth of the statement was suspected, it was
impossible to contradict the base fabrication (Note 21), as
time proved it to be. It is not to be wondered at, that under
the persistent misrepresentations of the press and such out-
rageous perjuries as that contained in the affidavit referred
to, Dr. Boylston should have been called before the town
authorities and peremptorily ordered to discontinue the
practice of inoculating for the smallpox. (Note 22.) The
utter want of truthfulness in Dr. Dalhonde's statement will
be manifest to any person who will reflect that there was no
inoculation known to the profession in Europe earlier than
that of the daughter of Lady Mary Wortley Montague, in 1721.
22

168 INOCULATION IN MASSACHUSETTS.

But even this hostile demonstration on the part of the
officials did not cause the doctor to abandon his philanthro-
pic work. The practice had to be conducted more secretly,
and this action of the authorities no doubt prevented many
from availing themselves of the security which the inoculated
disease gave of having it in a mild form, leaving them to the
chance of the casual disease, and lessening the number who
would have availed themselves of it.

Cautious and unobtrusive as he was in his practice, he
was greatly annoyed and persecuted (Note 23) and hamper-
ed in his work, but his friends came boldly to his support,
and encouraged (Note 24) him to continue a practice that
was daily manifesting its advantages over all others known
to the profession. Many of the clergy made use of their
position as ministers, and from the pulpit recommended inocu'
lation as safe and warrantable, and replied to the scurrilous
attacks upon themselves and the practice in the " Courant,"
and to the anonymous pamphlets (Note 25) which had teemed
from the English press and found their way across the
Atlantic. About this period several ministers preached and
published (Note 26) argumentative sermons showing that
the practice was in accordance with the teachings of reve-
lation.

The " Courant " continued its attacks, and was a thorn in
the side of the inoculators, to which they seemed very sensi-
tive. Franklin, the publisher, an elder brother of the cele-
brated Dr. Benjamin Franklin (Note 27), says, in his
paper of December 4, 1721, that about three weeks before,
he met a certain gentleman in the street, who, with an air
of great displeasure, addressed him in threatening and de-
nunciatory terms for opposing inoculation and confuting the
arguments of the ministers. This bellicose conversation did
not disarm Franklin or convince him of the sinfulness of his
ways. The publisher of the " flagitious and wicked Cou-
rant " was not to be intimidated by any such threats of ce-

INOCULATION IN MASSACHUSETTS. 169

lestial vengeance (Note 28), and he tells his readers that he
has thus been held up to public odium because he had
answered " a piece in the ' G-azette ' of October 30th, where-
in the greater part of the town are represented as unac-
countable liars and self-destroyers, for opposing the practice
of inoculation." And further says, that the people were so
exasperated about it that " at a town meeting soon after,
they moved that a committee might be appointed to find out
the author."

We must infer from these inklings of the controversy that
the blows were not all on one side, and the battle, so far as
it consisted in words, was pretty fairly brought out by both
parties. The editor of the " Courant " got into disfavor
with the government in 1722, his business fell off, his paper
lost support and influence, and shortly after it passed from
under his control.

It must be remembered that the temper of the age in
which these incidents transpired was coarse, and that the
theology of the people was intensely predestinarian. The
Mathers and most of the leading ministers of Boston who
were the pulpit organs of this theology were too practical
and too well informed to push their abstract religious theo-
ries to their natural conclusions ; but others were more per-
sistently logical, and stoutly maintained that as every man
had an appointed time to live on earth, it was only vain pre-
sumption to search for means by which to turn aside the
Divine decree or avert the fell destroyer. It was maintained
in the pulpit that the smallpox was a judgment sent of God,
as a punishment for the sins of the people, and it was not
extraordinary that the people should infer temerity and
wrong-doing in an attempt to turn away the punishment by
inoculation.

They maintained, naturally enough, that to put aside God's
chastisements would only offend Him the more. It was
declared from the pulpit that it was the right of God to

170 INOCULATION IN MASSACHUSETTS.

smite and afflict and chasten. It was said in reply by some,
that if it was a measure of Divine justice to send smallpox
to afflict man for his disobedience, it was therefore impious
to interfere between the Creator and his creature by inocu-
lation and such like inventions. Others saw in the multi-
plying of smallpox by artificial means a wilful tampering
with death, and believed that if a patient died from the
effects of the disease so induced, the inoculator should be
held responsible for murder.

Popular opinion and independence of action on the part
of the people was more emancipated from the governing
influence of the clergy by the inoculation controversy than
anything that had ever occurred in the colony. So much
did the ministers feel this to be the fact, that during the year
1722 they felt called upon to publish a vindication (Note
29) of their course in recommending the practice. This
document is couched in more becoming language than had
generally been used in these discussions, and their course
seems to have been just and humane throughout. With the
cessation of the disease the masses became indifferent about
the points of honor, and therefore no further controversy
was evoked by this document.

Throughout this whole controversy it is shown that when
men's passions are aroused, either side can justify its
course by specious arguments. But it is probable, after all,
that the animus of this portentous and threatening opposi-
tion existed chiefly in consequence of the encouragement
given to it by the opposing doctors. It is pretty evident
that they all disapproved of the course of Dr. Boylston at
the start, though some treated him with fairness and a few
were speedily made converts to the practice. (Note 30.)
But others remained uncompromising and exceedingly bitter.
The oath of Dr. Dalhonde is a sufficient evidence of his
feeling towards an associate practitioner. But Dr. Douglas
was scarcely less violent, and was more able and polished
in his opposition.

INOCULATION IN MASSACHUSETTS. 171

Hutchinson says : "Dr. Douglas made the most zealous
opposition. He had been regularly bred in Scotland ; was
assuming even to arrogance, and, in several fugitive pieces
which he published, treated all who differed from him with
contempt. He was credulous, and easily believed idle
reports concerning persons who, having received the small-
pox by inoculation, had afterwards taken it a second time in
the natural way ; of others who perished in a most deplor-
able manner from the corrupt matter which had so infected
the mass of blood as to render the patient incurable.*

The partisan and prejudiced conduct of the Selectmen has
already been alluded to ; but they did not stop with the
contemptible perjury of Dr. Dalhonde. At a subsequent
period the justices of the peace and the Selectmen had a
joint meeting (probably at the instance of Dr. Douglas and
his associates). This meeting summoned before them the
practising physicians of the town, who, under the excitement
of the moment, but, as they say, after u mature deliberation/'
agreed upon a bulletin, which was afterwards put before the
public in the following words :

" It appears by numerous instances that inoculation has
proved the death of many persons soon after the operation,
and has brought distempers upon many others which in the
end have proved deadly to them. That the natural tendency
of infusing such malignant filth into the mass of blood is to
corrupt and putrify it ; and, if there be not a sufficient dis-
charge of the malignancy by the place of incession or else-
where, it lays a foundation for many dangerous diseases."

It is no wonder that such scheming, persistent alarmists
should have succeeded in arousing the popular indignation
against Dr. Boylston. His position for a considerable time,
in consequence, was one of great peril. Thatcher tells us
that the enraged populace at one time were bent on his de-

* See Hutchinson 's History of Massachusetts Bay, vol. 2, p. 274.

172 INOCULATION IN MASSACHUSETTS.

struction, and that " they patrolled the town in parties, with
halters, threatening to hang him on the nearest tree. The
only place of refuge left him at one time was a private place
in his own house, where he remained secreted fourteen days,
unknown to any of his family but his wife. During this time
parties entered the house by day and by night in search of
him. Nor was this all. Their rancor extended to his family.
For one evening while his wife and children were sitting in
the parlor, a lighted hand grenade [similar to the one used
on another occasion at the house of Rev. Dr. Mather] was
thrown into the room. But the fuze striking against some
of the furniture, fell off before an explosion could take
place, and thus providentially their lives were saved. Even
after the madness of the multitude had in some measure sub-
sided, Dr. Boylston ventured to visit his patients only at
midnight and in disguise."*

The labors of Dr. Boylston, as exhibited by the very re-
spectable number of cases given in his tables, would have
been doubled or trebled but for the violent persecution which
was raised against him. But as soon as the alarm of the
people had passed away and their passions had subsided,
they were enabled to see with a clearer vision, and balance
with a more correct judgment, the advantages and disadvan-
tages of inoculation as a means of protection from the
severity and danger of the casual smallpox. The number
of cases that had undergone the operation, with the recog-
nized accuracy of the report, formed a reliable basis on
which " sober second thought " might rest its further action,
with a confiding faith which wrong-headed doctors, self-willed
magistrates and perjured zealots could not destroy.

* Sec Thatcher's Medical Biography, vol. 1, p. 187.

CHAPTER III.

Spread of inoculation in the colonies — Earliest inoculating hospitals — Dr. Boyls'-
ton and the Councilmen — The epidemic smallpox of 1730 — Opposition to
inoculation less influential — Dr. Douglas — The epidemic of 1752 — Inocula-
tion embarrassed by laws — Tabular exhibit of the casual and inoculated dis-
ease— A dastardly attempt to convey the contagion — Epidemic of 1764 — Hos-
pitals established, but soon forced to close — Suttonian system introduced—
Hospital burnt by a mob — Management of hospitals — Smallpox in the Ameri-
can army — Inoculation hospitals established by authority — A permanent one
at Brookline — Epidemic of 1792 — A general inoculation followed — Dr. Boyls-
ton and his visit to England — His book on inoculation in America — His
death and tomb.

A knowledge of the practice of inoculation, with the re-
sults of the numerous cases of Dr. Boylston, soon spread to
the other American colonies, and as the people became fa-
miliar with the new practice, it grew more and more into
favor. The simplicity of the operation, and the uniform
mildness of the symptoms developed during the progress of
the disease, brought it in some degree within the scope of
domestic practice. In the interior settlements, where doc-
tors were scarce and could only be had by riding long dis-
tances, inoculations were frequently made by the common
people, and the patients were said to have passed through
the various stages of the disease with about the same general
results as in cases managed by the profession.

Insulation of the infected, which is so important in pre-
venting the spread of every contagious disease, was more
readily attainable in the sparsely peopled settlements of
the colonies than in the densely populated districts of the
mother country. But the danger of spreading the smallpox
was nevertheless a great hindrance to the practice of inocu-
lation even here, and this danger, added to the natural
shrinking from a hazardous disease, caused many to put off
the inoculation as long as possible ; and it was only in con-

174 INOCULATION IN MASSACHUSETTS.

sequence of some great alarm from the near vicinity of the
disease that the people could be brought with any unanimity
to accept the protection which it afforded. But the suppres-
sion of smallpox, and the complete protection of society, re-
quired that every person should be inoculated ; but as no
such general inoculation could be had in a new, sparse, and
free community, the consequence was that the disease con-
tinued to make its unwelcome incursions at irregular periods,
and though divested somewhat of its former terrors, it was
still a most dreaded visitant. Whenever, therefore, variola
became prevalent, inoculators were thronged with applica-
tions to administer the disease artificially, in preference to
running the risk of taking it casually.

Public hospitals for the insulation of the sick with conta-
gious disease were as yet hardly known in America. The
earliest mention which we can find of the erection of any
building devoted exclusively to this class of cases is in 1 701,
when the inhabitants of Salem, Mass., Yote&Jifty pounds ster-
ling to hmld a "pest house." Prior to that time vacant
buildings in the outskirts of towns had been used, and con-
tinued to be used, for that purpose in many places until a
much later date. In 1717 the Selectmen of Boston were
authorized to have an acre of land on Deer Island for a hos-
pital, or, as it was then termed, a " pest house." But after
the smallpox epidemic of 1730 had subsided, a permanent
hospital building was erected on the island for the special
purpose of treating persons sick with contagious diseases.
It had in view the twofold object of providing suitable ac-
commodations and medical attention for all persons suffering
from infectious diseases, and their separation from the rest
of the community. Mr. Drake, in his History of Boston,
speaks of it as u a good and convenient house on the island
called Rainsford's Island, for the reception of such persons as
might be visited with any contagious sickness." This was
the beginning of the Boston hospital, which has since received

INOCULATION IN MASSACHUSETTS. 175

an army of patients and relieved a vast amount of human
suffering. This institution has continued to keep pace with
the demands of the times, and has become one of the most
celebrated curative establishments in our country. Its man-
agement is under the joint direction of the city and the State.
The example set by Boston was soon followed by other
commercial places, so that in a few years there were but few
towns of any considerable size which had not provided a
refuge for their sick. ; •

When the great smallpox epidemic of 1721 was prevail-
ing in Boston there had been established no sufficient health
regulations or complete system of insulation of the infected
from the well, although the authorities were as prolific in
enactments as if they expected to keep off contagion by
mere force of law. The disease disregarded all the re-
straints devised to check it, and swept on over the town
with such fearful havoc as to make it one great hospital, in
which every house was but an additional ward, with its pa-
tients and nurses. The General Court, which came together
on the 3d of November of that year, took the alarm, and,
after a session of four days, was removed on the 7th to
Cambridge. One of the members from Boston, Mr. Hutch-
inson, was immediately seized with the distemper, and died.
(Note 31.) Mr. John White, who had been Clerk for many
years, sought to protect himself from the danger attendant
upon the casual disease by inoculation, but was one of the
unfortunate six who died under the care of Dr. Boylston.
Many of the inhabitants, as has been hinted, fled from the
town and sought safety in the isolation of country habita-
tions, and doubt and alarm seized upon the great body of
the people. So great was the fear, that even after the Gen-
eral Court had been removed to Cambridge, its members
could not be kept together, and it was prorogued by the
Governor after a fruitless session of eight or ten days. It
was thus under a high state of general alarm that Dr. Boy Is-
23

176 INOCULATION IN MASSACHUSETTS.

ton pursued the practice of inoculation, and there is little
doubt, in view of the strong opposition on the part of the
doctors, and their disposition to bring it into disrepute, that
they represented that what he did had a tendency to increase
the spread and mortality of the casual disease, A cotempo-
rary historian* says u that the magistrates supposed it (mean-
ing inoculation) had a tendency to increase the malignity
and prolong the continuance of the infection, and that there-
fore it behooved them to discountenance it." It was the
same conviction which caused the General Court to consider
the matter. The House of Representatives initiated it, and
actually brought in a bill and passed it, " prohibiting all
persons from inoculation," but the Court was in doubt, and
the bill failed to become a law.

Notwithstanding Dr. Boylston's earnestness, perseverance
and courage, there is some ground for believing that he did
finally yield somewhat to the strong prejudices of the com-
munity, and forbore the practice in deference to their opin-
ions. Felt, in his Annals of Salem, quotes an order from
the Boston Selectmen, bearing date May 21, 1722, a part of
which is as follows : " Dr. Boylston declaring at a public
town meeting that he knew of no more than these six men
under inoculation for the smallpox, did solemnly promise to
inoculate no more without the knowledge and approbation
of the authorities of the town."

Although we can find no corroborative statement of the
Doctor's public avowal of a determination to desist from the
practice of variolation, yet, as the record of the order shows
it to have been as late as the middle of May, 1722, when the
smallpox had almost disappeared and the motive for inocu-
lation was no longer urgent, he no doubt thus sought to quiet
the public mind by a pledge to the authorities of the town.

Boston was again visited by smallpox in 1730, after an

* Hutchinson, History of Massachusetts Bay,

INOCULATION IN MASSACHUSETTS. 177

exemption from its ravages for nine years. The town in
these intervening years had considerably increased in popu-
lation * and all who had been born there since the last epi-
demic, with the addition of a considerable number of emi-
grants from abroad, as well as many who had come in from
the country, were unprotected and liable to the infection.
On this occasion the smallpox was brought to the city, by a
vessel from Ireland, the preceding fall, but was confined
during the winter to a few families living about the place
where the ship in which it came discharged its cargo. In
March it gained a footing in the town, and spread rapidly
in every direction, producing great consternation, and caus-
ing many, as on former occasions, to flee to the country for
safety. For the greater security of those attending the Gen-
eral Court, it was convened in Cambridge instead of Boston,
but as the disease spread, that place was not regarded as
safe from its approaches, and the Court was again moved to
Roxbury.

The opposition to inoculation at this period had lost much
of the sharp and revengeful form it had previously taken,
and no obstacles were now interposed by the Selectmen to
prevent such as desired to accept the disease, in its milder
form, from having it engrafted upon them. But still the old
prejudice, as may be supposed, retained some of its vitality, as
the whole number inoculated during this epidemic probably
did not exceed 400, while the whole number that had the
smallpox in the casual way was over 4,000. Of this large
number about 500 died, showing one death in every eight
persons attacked; whereas of the 400 inoculated twelve
only are said to have died, which would be an average mor-
tality of one in 33. (Note 32.) But this number, it must
be remembered, was the estimate of Dr. Douglas, still a
stubborn enemy of the new practice. The contagion reached

* The population of Boston in 1730 was estimated at 15,000.

178 INOCULATION IN MASSACHUSETTS.

its height in June, and from that time gradually declined,
and ceased entirely during the winter.

Smallpox re-visited Boston in 1752. For over twenty
years the people had been wholly exempt from this dread
destroyer, and a new generation, who were entirely unpro-
tected against its advances, had arisen to fill the ways of
business and provide for the public weal. The population
of the town in the meantime had not materially increased,
the emigrants being of late mostly agriculturists, and the
speculative attractions of the country drawing somewhat on
the surplus laborers of the towns. In the absence of any
apparent danger from small-pox, inoculation made no pro-
gress, so that this outbreak or presence of the contagion
took the people by surprise. The disease, as on former oc-
casions, had been imported. A vessel from London, with
smallpox on board, had struck on the bar on entering Nahant
Bay, and bilged. This was on the 24th of December, 1751,
in the depth of the northern winter, when wrecks are apt to
prove peculiarly disastrous to life. But the people of Chelsea
and the surrounding towns, with great heroism, Succeeded in
reaching the vessel, and saved the crew ; a noble act, which,
however, cost them afterwards many valuable lives, for the
rescued crew brought with them the seeds of variolous infec-
tion, which soon found its way to Boston, where it raged
with fearful havoc for many months.

The disease reached Boston in January, through one of
the sailors, and soon began to spread and create an alarm
among the citizens. To enable the people to avoid houses
where the infection had manifested itself, it was ordered that
a flag should be hung out as a warning, which was doubtless
a wise precaution. It rapidly became epidemic, and proved
to be of the most malignant type. By March it had fairly
invaded every block and street in the town, and on the 23d
of that month inoculation was commenced. (Note 33.)
Old prejudices against the remedy having pretty much died

INOCULATION IN MASSACHUSETTS.

179

out; and the danger being imminent; the resort to it was
much more general than on any former visitation of the
disease. But lest the practice of inoculation should have
the effect of continuing the contagion after the epidemic
might have run its course, the Selectmen requested the doc-
tors to cease all inoculations as soon as the casual disease
showed symptoms of declining; which they did on the 27th
of July.

From the 1st of January down to the time when inocula-
tion ceased; or, as some have it, down to the 24th of July;
there had been, according to the statistics collected by the
Selectmen, 7,653 cases of smallpox, and 545 deaths, as
follows :

Had the smallpox by contagion — white
" " black

Had the smallpox by inoculation — white
" " black

Number of
Cases.

Deaths.

5,059
485

1,970
139

452
62
24

7,653

545

Ratio of Deaths.

linll
lin 8
lin82
lin 20

1 in 14

At the time these facts were collected there were still 23
persons sick in 17 different families, and there remained in
the town 174 who had not taken the disease.

These figures show the number that were attacked by the
casual disease, also those by inoculation, and that, partial as
the practice had been; many lives were saved, to say nothing
of the suffering which was prevented.

During the continuance of the contagion, hospitals were
extemporized in favorable localities and nurses pressed into
service by authority of the town to care for the afflicted.
The police regulations of the town, and the accommodations
and medical treatment of the patients, showed a decided
advance in the management of the disease over termer epi-
demics.

180 INOCULATION IN MASSACHUSETTS.

From Boston this variolous pest spread into the adja-
cent towns and villages, and thence through most of the
colonial settlements. Tillages, to protect themselves, placed
guards at their entrances, fenced up roads and bridges to
prevent communication with infected places, and used every
means in their power to isolate themselves from such
districts. It is not known what were the precise results of
these precautions, but it cannot be doubted that such a course
would delay the progress of the disease, if not protect many
places from its scourge.

It is a well-known fact that all great excitements have a
tendency to demoralize society, and a curious instance of the
fact was exhibited by some parties in Marblehead during the
prevalence of this epidemic. This was an attempt to com-
municate the smallpox to Judge Lynde's family. The Judge
was naturally very indignant, and offered a reward of £500
for the detection of the miscreant, and Lieut.-Governor
Phipps issued a proclamation, the object of which was to
aid in the detection of the perpetrator, and to deter others
from committing similar outrages.*

The next visitation of smallpox to Boston and the State
of Massachusetts was in 1764. The most important public
event which took place during this epidemic was the estab-
lishment of inoculating hospitals. Petitions to the General
Court were circulated, and a formal grant was enacted,
under which three such hospitals (Note 33) were opened for
the reception of patients. The success of these institutions
was by no means commensurate with the expectations enter-
tained by the friends of the measure. The impression
became general that the disease spread from the hospital to
residents in the neighborhood, so that the Court revoked
their charter, and the reception of patients was discontinued.
Whether the control over the patients was not strict enough

* Felt's Salem, vol. 2, p. 425.

INOCULATION IN MASSACHUSETTS. 181

to prevent all intercourse with the inhabitants, as it should
have been, we cannot say, but we are inclined to suspect
that this was made the pretext to have them abolished.
Keports and contemporary accounts assure us that scarcely
a single death occurred among those inoculated in these
institutions, and their discontinuance was only in deference
to public opinion

A knowledge of the improved mode of inoculating for the
smallpox and the treatment of the disease instituted by Mr.
Sutton in England, was put in practice in America in 1773.
James Latham opened a hospital in Salem, Mass., that year,
where he practised upon the Suttonian plan, and had a fair
degree of patronage and success. At one time he had 132
patients in his establishment under treatment, at another
137, and later, in 1777, there were 216 entered for inocula-
tion at one time. The adoption of this plan enabled the doc-
tor to greatly abridge the period of treatment, and, by the
judicious employment of capital and labor, he brought the
price so low as to be within the means of all. (Note 34.)

But the people in all parts of the Commonwealth were
not even yet quite reconciled to the idea of nursing conta-
gion in hospitals, and being persuaded that the building on
Roache's Point used by this class of patients would eventu-
ally spread the smallpox among the surrounding inhabitants,
they became excited, and gathering in a mob on the 26th of
January, 1774, burnt it to the ground. (Note 35.) Its loss
was subsequently supplied by another, which was erected on
the Neck. In 1773 the people of Marblehead obtained an
order to build a smallpox hospital on Cat Island. This is
an excellent location, being perfectly insulated. It contains
over nine acres of land, and has an excellent spring of fresh
water at its southeast end.

Salem was again visited by smallpox in 1792, when it
was attended with the usual mortality. There were inocula-
ted in the town during this epidemic 710 persons, and in the
neighborhood 275 more, of whom only five died.

182 INOCULATION IN MASSACHUSETTS.

When the American Revolution opened, in 1775, inocula-
tion was practised in all the colonies as an approved remedy
against the dangerous and much-dreaded visitations of small-
pox : but it was not deemed so safe or agreeable as to cause
it to be generally adopted except in time of imminent danger
from the original contagion. Hence it never obtained to
such a degree of general patronage as to make it a protec-
tion to the great mass of the people, and consequently when
smallpox invaded the army, gathered as it was largely from
interior districts where the disease seldom penetrated in an
epidemic form, it found an unusual portion of unprotected
persons, and proved more destructive to life than the guns
of the enemy. It continued during the earlier years of the
war to be the scourge of the camps, and prevailed to an
alarming degree wherever our armies were stationed. The
havoc which it made among the troops in 1776 was so great,
that had the British commanders been acquainted with our'
deplorable condition (Xote 36) they might have marched
almost without opposition through the country, even where
our defences were strongest.

Strong corroborative testimony of the beneficial results
obtained for the army by universal inoculation is given by
Dr. Ramsay, who was an eminent surgeon (Xote 37)
throughout the glorious campaigns which achieved our inde-
pendence, and also an esteemed chronicler of events.

The smallpox broke out in 1776 among the soldiers of
the American army encamped in the town of Cambridge,
when nearly the whole body of them was inoculated by Dr.
Bond, an aged and experienced physician, who, when young,
had been cotemporary as a practitioner of medicine with
the latter days of Dr. Boylston, the earliest and ablest
champion of that salutary art in America. He had thus
enjoyed frequent opportunities of conversing with the doctor
upon a subject which had so largely engaged his attention.
Some idea may be formed of the neglect of this practice,

INOCULATION IN MASSACHUSETTS. 183

even at this late day, among the people, when the doctor was
called upon during the same year, and within a few weeks,
to inoculate twenty-nine practitioners of medicine.

Professor Waterhouse, in one of his letters to Dr. Hay-
garth, in speaking of this wise precaution against one of the
chief enemies of human life, the variolous contagion, says :
"When General Washington inoculated his New England
army, there were scarcely men enough free from the disease,
or not liable to take it, to keep guard at the different hospi-
tals."

A further protective measure of great value was the
establishment of permanent hospitals for inoculation, which
were to be kept open for the reception of patients at all
times. (Note 38.) Such a hospital was established in
Brookline, and continued for a long time under the direction
of Dr. Aspinwall, the successor of Dr. Boylston. He was
a man of ability in his profession, and had extensive expe-
rience in the treatment of the epidemic or casual smallpox
and the inoculated disease. Heretofore when an epidemic
had ceased its ravages, the hospitals which had been extem-
porized were immediately closed; but henceforth they were
to be open at all times, and the fault would be with the
people if they did not avail themselves of its advantages.
For years numbers of persons flocked to Dr. Aspinwall's
hospital to be carried through the disease, and returned
home with warm expressions of their satisfaction and confi-
dence in his skill. The percentage of deaths at the hospital
was never greater than one in two hundred. This estab-
lishment was maintained with increasing popularity until the
discovery of vaccination, which robbed it of its patronage.

The smallpox again visited Boston, and the New England
States generally, in an epidemic form, in 1792. To appease
the alarm of the inhabitants (Note 39) respecting the danger
of infection from the dreaded disease in the casual way, and
in compliance with the popular wish to receive the inocula-
24

184 INOCULATION IN MASSACHUSETTS.

ted disease, the authorities consented; and all the unprotect-
ed citizens submitted themselves to the operation within three
days. The want of preparation on the part of patients, and
the hurry and confusion attending the practice on so large
a scale, precluded the possibility of giving in every instance,
either in the primary operation or when the disease de-
veloped itself, all the requisite attentions necessary to insure
the most satisfactory results.

The number of inoculations at this time was 9,152, per-
formed without any discrimination or preparation. Out of
this number 102 deaths are said to have occurred. The
mortality was almost exclusively confined to the poorer class,
many of whom were entirely destitute of the necessaries of
life, and in many instances without the advice of a physician
or the aid of a nurse.

Dr. Boylston, who inaugurated in America the great
changes in the professional mode of dealing with smallpox
which have been briefly sketched in the preceding pages,
lived to witness the success of many of them, and enjoyed
the triumph of common sense and experiment, guided by
skill, over prejudice and superstition. He did not pass " to
that bourne from whence no traveller returns" till 1766.
His great battle with the medical conservatives and popular
ignorance, which gained him his high distinction, was fought
in 1721. The clouds which for a time gathered around him
in those dark hours of doubt and uncertainty were soon dis-
pelled, and he came forth from his place of concealment
and from the persecution of the populace and the ban of his
professional brethren, to take his place among the leaders
and heroes of the world's history. Accounts of what he
had accomplished found their way across the Atlantic, and
were favorably commented upon in professional circles and
noticed in the publications of the Royal Society. Not only
had his name survived the avalanche of opprobrious epithets

INOCULATION IN MASSACHUSETTS. 185

which envy and ignorance had heaped upon it, but his zeal
in the cause of humanity had indelibly engrossed it upon the
scroll of imperishable honor.

In 1723, two years after Drs. Douglas and Dalhonde had
exiled him in disgrace, as they supposed, under the official
edict of the Justices of the Peace and the Selectmen of
Boston, he received from Hans Sloan, Physician to the King
and President of the Royal Society, an invitation to visit
England and confer with the savans upon the subject of
inoculation. He accepted the invitation, and a year or two
later crossed the Atlantic. His cordial reception by the
leading physicians in London was a proud day for the con-
temned and vilified doctor. He was received into the
choicest literary circles, was introduced at court, pre-
sented to the royal family, and elected a member of the
Royal Society. But, most important of all, he published, in
1726, at the request of the Royal Society, a particular ac-
count of his inoculations in New England. This book is a
complete record of his labors, as well as a most valuable
addition to the literature of the subject. By permission he
inscribed the volume to Caroline, Princess of Wales, soon to
become Queen of England.

It is supposed, too, that these special marks of approba-
tion from royalty were attended by some munificent endow-
ment from the national treasury, for soon after his return to
his cherished home in New England, he appeared to be not
only loaded with honors, but was also possessed of wealth.
His work on Inoculation in America was re-published in
Boston in 1727. A copy of this edition has been given by
one of his descendants to the library of Harvard University.

About this period he took up his residence on his patri-
monial estate in Brookline, and devoted himself to science
and literature, though remaining for many years the ac-
knowledged head of his specialty in New England. He
contributed many valuable articles to the Royal Society.

186 INOCULATION IN MASSACHUSETTS.

Agriculture had special attractions for him, and he beauti-
fied and enriched his valuable farm. He indulged his taste
for fine horses; and took great pride in improving the breeds
of domestic animals. He lived at his ease, and saw inocu-
lation widely practised without fear of the squibs of the
" Courant," or the official bulletins from the Selectmen.

Dr. Boylston died in 1766, having attained to a ripe old
age and a wide celebrity throughout the world for his philan-
thropy. His sincerity of character and urbanity of manner
caused him to be greatly beloved by the community in which
he lived. His remains were interred on his patrimonial
estate, and his tomb bears the following inscription : " Sacred
to the memory of Dr. Zabdiel Boylston, physician and Fellow
of the Royal Society, who first introduced the practice of
inoculation in America. Through a life of extensive benefi-
cence he was always faithful to his word, just in his dealings,
and affable in his manners, and, after a long sickness, in
which he was exemplary for his patience and resignation to
his Maker, he quitted this mortal life .on the 1st day of
March, A.D. 1766, aged 87 years."

NOTES .

Note 1. (Page 154.)

In a letter by Dr. Douglas (who was an earnest opponent of inoculation),
written to Dr. Cadwallader ColdeD, of New York, May 1st, 1722, there is given
an amusing account of the effect produced by loaning these books. He says,
" Having, sometime before the smallpox arrived, lent to a credulous vain
preacher (Mather, Jr.) the Philosophical Transactions (Nos. 337 and 339) which
contain Timoni's and Pylorini's accounts of inoculation from the Levant, that
he might have something to send home to the Royal Society, which had long
neglected his communications as he complained, he sets inoculation to work in
June, and by the 18th November one hundred were inoculated ; and by Janu-
ary, in all, some few more than 250 in town and country." — (Quoted in Drake's
History of Boston, p. 562.)

Dr. Boylston, in his work, alludes to the Transactions of the Royal Society,
containing the letter of Timoni and Pylorini, and says : " Dr. Douglas, who
owned them, and had taken them from Dr. Mather, refused to have them read,
such was his extraordinary care lest the people, in time, should have been re-
conciled to the practice and take the benefit of it."

Note 2. (Page 154.)
The Selectmen of Boston, in their report of July 22d, 1721, say that " the
small-pox was communicated to the town about the middle of April, being
brought there by the Saltortuda's [Saltortugas] fleet." Dr. Douglas also dates
its appearance about the same time, as may be seen in his letter to Dr. Cadwal-
lader Colden, bearing date July 28th, 1721, in which he says : "It was imported
here [meaning the smallpox] about the middle of April last, from Barbadoes?
via Saltertuda."— (Mass. Hist. Coll.)

Note 3. (Page 154.)
It is a fact worthy of note in the history of medical literature on this conti-
nent, that the earliest medical tract printed in America of which we have any

188 INOCULATION IN MASSACHUSETTS.

record, was upon the subject of smallpox and measles. The work alluded to
was published in 1677 by Thomas Thatcher, a minister of the gospel as well as a
practising physician. The title of the treatise was, " A brief Guide in the Small-
pox and Measles." The earliest date at which the title of " doctor " is found
prefixed to that of physician in Massachusetts is in 1779, after which period the
person so titled was forbidden to wear his sword.

i
Note 4. (Page 154.)

From the first settling of the Province of Massachusetts Bay, the smallpox
had been epidemic in Boston eight times up to 1752, viz., in 1649, 1666, 1678,
1689, 1701, 1721, 1730, and 1752.— {Douglas's Summary, vol. 2, p. 395.)

Note 5. (Page 155.)

Dr. Boylston, in his " Historical Account of Inoculation in America," after
mentioning the fact that Rev. Mr. Mather had transcribed the articles from the
" Transactions," and sent copies to all the doctors, adds : " Upon reading of
which I was very well pleased, and resolved in my mind to try the experiment ;
well remembering the destruction by the smallpox nineteen years before, when
last in Boston, and how narrowly I then escaped with my life." It appears
from a pamphlet known as " A Vindication of the Ministers of Boston," that
Dr. Mather sent, with the manuscript copies of the articles on the Turkish
Inoculation, a circular letter of his own, in which he suggested, with great pro-
priety, that the doctors should hold a meeting and agree on the course which
they would take in relation to the proposed new remedy. He justly remarks
in the circular that " whoever first begins the practice, if approved that it
should be begun at all, may thus have the concurrence of his worthy brethren
to fortify him in it." The circular letter, and the copies made of Timoni's and
Pylorini's account of the practice, were sent on the 6th of June, 1721, but the
physicians never met or consulted as proposed, and therefore nothing was done
by concert.

Note 6. (Page 155.)

Dr. Zabdiel Boylston was the grandson of Thomas Boylston, who at the
age of 20 emigrated from London to America, and settled near Watertown,
Mass. The emigrant was the son of Henry Boylston, of Litchfield, in England.
Thomas was a farmer, and died in 1653, at the age of 38, leaving a wife and
three children. The youngest, a son, Thomas, was bom in 1645. He devoted
himself to the practice of medicine and surgery, and settled in the region of
Muddy River, a part of Boston till 1705 (now Brookline), to practise his pro-

NOTES. 189

fession. During the King Philip "War he acted as Surgeon. He acquired by
his practice considerable property, and lived the remainder of his days in
Brookline, where he died in 1695, at the age of 51, leaving a wife and numerous
children. His will was probated on the 16th of the following December. Zab-
diel Boylston, the subject of this note, was the seventh of his twelve children,
and was born at Brookline in 1679, according to his baptismal registration,
which is on the 9th of March of that year. Zabdiel received a liberal educa-
tion for the period in which he lived, and prosecuted his medical studies partly
with his father, and partly with Dr. John Cutler, an eminent physician and
surgeon then practising in Boston.

After completing his course of medical studies, he settled to practise his
profession in the town of Boston, where he received a liberal share of patron-
age. Possessing a philosophical turn of mind, he was studious in his habits,
sedate in his manners, and was scrupulously correct in his principles, so that
he soon won the confidence of the whole country. "When the subject of inocu-
lation was brought to his attention as a remedy to control the severity and les-
sen the mortality which followed casual smallpox, he gave it his serious atten-
tion, and became convinced of the propriety and safety of the practice, and
labored to induce the different members of the profession in Boston to unite in
a concerted and public trial of the proposed remedy ; but failing in this, he
boldy assumed the responsibility himself, and won a distinction which abun-
dantly compensated him for all the obloquy which for a time he was obliged to
endure from the opponents of the practice. I am indebted to Bond and Drake
for most of the facts in Dr. Boylston's genealogical history. Thatcher, in his
Medical Biography, has been singularly unfortunate in giving the doctor's
genealogy, although he credits the information he relates to members of the
Boylston family.

Note 7. (Page 155.)

Cotton Mather was the oldest son of the Rev. Dr. Increase Mather, and
was born in Boston in 1662. His mother was the daughter of the famous John
Cotton, a minister of Boston. He graduated, at the age of 16, at Harvard Col-
lege, in 1678, and was ordained to the ministry in 1684. The Rev. Cotton
Mather was a man of prodigious industry, and capable of performing the great-
est literary labors with surprising rapidity. It was said of him that he could
read a folio of several hundred pages and write a sermon in a forenoon. He
became acquainted with a subject and grasped its facts by a sort of intuition.
His eccentricities were great, which caused his motives at times to be mis-
understood. Never being neutral upon any subject or question of policy, it is
not wonderful that he had enemies. He wrote too much to write well always.
He possessed the greatest versatility of mind, and was always engaged in some
literary or scientific investigation. He was a close observer of the physical
phenomena of nature, and some of his observations were quite original, and
entitle him to credit. He has left a record of some original facts observed in
connection with smallpox, regarding the vexed question of whether it does
attack animals. He says that " some cats, in 1721, in Boston, had the regular
smallpox, and died of it ;" and further adds, that "during the prevalence of the
disease the pigeons and dunghill fowls did not lay or hatch."

190 INOCULATION IN MASSACHUSETTS.

It was believed, at this period, by well-informed persons, that many of the
domestic animals were liable to diseases similar to those that attacked the
human race. Mather contended that this was absolutely true with regard to
smallpox, and later observations by scientific men in Europe have substan-
tiated this fact.

In Massachusetts, in 1756, this belief had gained such an influence among
the people that a war almost of extermination was carried on against cats and
dogs, on the ground that they spread the contagion of smallpox from house to
house and from one person to another. An order was carried before the town
council at Salem as late as the fall of 1773, through the influence of Thomas
Heather, " that dogs and cats be killed, lest they spread the contagion of small-
pox."— (See Felt's Salem.)

DeFoe, in his History of the Great Plague that prevailed in London in 1665-
66, says that great numbers of dogs and cats were killed because it was
believed they served as a means of spreading the disease.

Note 8. (Page 156.)

Rev. Increase Mather was a noted and influential man throughout the New
England settlements. His ministerial labors extended through a period of
sixty-six years, and for sixty-two years he ministered in the same Church.
He was honored with the Presidency of Harvard University for twenty years.
The Province of Massachusetts Bay selected him as their agent to England, in
which capacity he served them for some years. His belief in witches and his
connection with the punishment of persons suspected of possessing demoniac
powers, has thrown a shadow over his memory, but aside from this he enjoyed
a lon^ and honorable life.

Note 9. (Page 156.)

Benjamin Colman, a minister of Boston, wrote and published, in 1720, a
pamphlet entitled "Some Account of the New Method of receiving the small-
pox by engrafting or inoculating," in which he made an able defence of the
practice from a moral standpoint of view, justifying Dr. Boylston and other
inoculators, and encouraging persons to receive the disease by this method
rather than run the risk of being infected with the casual disease, which all
knew to be so hazardous to life. Many sermons were preached in defence of
the practice, a few only of which have been preserved.

Note 10. (Page 156.)
One of the Rev. Increase Mather's sermons on this subject has been pre-
served. It was preached at a time when Dr. Boylston had inoculated about 100
persons. The sermon is entitled, " Several reasons proving that Inoculation,
or transplanting the smallpox, is a lawful practice, &c."

NOTES.

191

Note 11. (Page 156.)

Dr. Boylston says : " On the 26th June, 1721, 1 inoculated my son Thomas, of
about six ; my negro man Jack, thirty-six ; and Jackey, two and a half years old."

These were unquestionably the first inoculations on the American continent,
and at that time the Doctor was not acquainted with the fact that the practice
had been commenced in England. The variolous disease in these cases devel-
oped regularly, and was of the mildest kind. They all recovered speedily, and
without any unfavorable symptom whatever. — (See Zabdiel Boylston's Histo-
rical Account of Inoculating the Smallpox in New England.)

In regard to dates, we have followed Dr. Boylston, who is undoubtedly cor-
rect. His dates, too, are corroborated by Dr. Douglas, who says, in a letter of
May 1st, 1721, that he lent the books before the smallpox arrived, and that he
(meaning Mather) set inoculation to work in June. The report of the Select-
men also connects the inoculation movement with the prevalence of the small-
pox, which was in 1721. But all authorities do not agree upon the year. There
is published in the Massachusetts Historical Society Collections a letter from
Dr. Franklin, addressed to Dr. Heberclcn in 1759, in which he says, " Inocula-
tion was first practised in Boston by Dr. Boylston, in 1720. It was not done
before in any part of America, and not in Philadelphia till 1730."

The same date is given by Dr. Bartlet, in his account of the early history of
medicine in the American colonies, published in the Massachusetts Historical
Collections. He says, alluding to Dr. Boylston, his experiments commenced on
his own son in 1720. The dates given by Franklin and Bartlet are evident blunders .

Note 12. (Page 156.)
The following table, from Dr. Boylston's work, gives a complete history of
the cases :

•'

Number

Had the

Suspected of

Ages of Subjects.

smallpox by

No effect.

having died of

inoculation.

From 9 months to 2 years old

" 2 years to 5 "

« 5 " " 10 "

u 10 « « 15 a

" 15 " " 20 "

" 20 " " 30 "

" 30 " " 40 "

" 40 " " 50 "

" 50 " " 60 "

" 60 " " 70 "

244

238

Inoculated by Drs. Koby & Thomp- ?
son in Roxbury and Cambridge. J

280

274

Two inoculated by Dr. Boylston, \
after his tables were printed. J

282

274

192 INOCULATION IN MASSACHUSETTS.

Note 13. (Page 156.)

The year was not commenced with uniformity among early nations. The
year of the Egyptians, the Jews, and the Greeks, corresponded neither with
that of the Romans, nor with each other. To avoid perplexity in the dates met
with in ancient records, it is necessary to pay some attention to this fact, and
particularly to the practice of double-dating in vogue among our ancestors.
The length of the actual year is determined by the exact time required for the
earth's revolutions round the sun. This time was closely approximated, though
not correctly ascertained by the ancients, owing chiefly to the imperfection of
the instruments with which they made then observations. But with such
nicety has this period been determined by modern astronomers that it is now
known to every schoolboy that 365 days 5 hours 48 minutes and 49 seconds and
seven-tenths of a second, is the exact time required by the earth to complete
its circle.

The old Roman year consisted originally of ten months, and began to com-
pute with March, as is evident from several of the names which are still retain-
ed in use, as Quintilis, Sextilis (answering to July and August), September,
October, November and December.

To these ten, the second King, Numa Pompilius, whose reign ended about
672 years B.C., added two others at the close, viz. : January and February.
These twelve months were lunar, and consisted of twenty-nine days and a half
each, making but 354 days in all. The difference between the lunar and solar
year was made up, or intended to be made up, by an intercalation of a month
every second year, to consist alternately of 22 and 23 days. But this interca-
lation was made irregularly, and great confusion in the times, seasons and festi-
vals named in the calendar ensued. To remedy these evils, Julius Caesar, no
less eminent as a scholar than as a statesman and military commander, under-
took and put in practice a more correct system of dividing the year. He
abolished the use of the lunar computation, and, with the aid of Sosigenes, an
eminent astronomer of Alexandria, computed the solar year to be 365 days and
6 hours. Here it will be perceived that an error of a few minutes in the year
was continued. He directed that the civil year, as a matter of convenience,
should be reckoned to consist of 365 days for three successive years, the fourth
to have an additional day, added to February, to absorb the surplus hours,
thus making every fourth year to consist of 366 days. The year in which this
intercalation is made is called*Bissextile, on account of the addition, or twice-
reckoning. Leap year is explained thus in a prayer book of Queen Elizabeth's
time : " When the years of our Lord (i. e., when the number of years from the
birth of Christ) may be divided into four even parts, which is every fourth year,
then the Sunday letter leapeth, and that year the Psalms and Lessons which
serve for the 23 d of February shall be read again the day following, except it
be Sunday," &c.

Julius Caesar also decreed that the kalends of January (January 1) should be
fixed as the winter solstice, and should thenceforth be the beginning of the cur-
rent year, on which day " all the annual magistrates of the Romans first enter
on their offices."

The Catholic Church adopted the Julian or Roman calendar, and it was for
many ages observed by all Christian nations. Had the solar year coincided
exactly with the time calculated by the Julian method, there would have been
no occasion for any alteration. But the time recorded by it exceeded the solar

NOTES. 193

year by 11 minutes 10 seconds and 3-10 of a second ; consequently the conven-
tional year had fallen, in 1582, about ten days behind the real time.

At the time of the Council of Nice, which sat A.D. 325, the vernal equinox
was upon the 21st of March ; but in 1582 it returned as early as the 11th of the
month. This deranged all fixed anniversaries and festivals, and caused such
serious annoyances in ecclesiastical feasts designed to commemorate the re-
markable events connected with the birth, mission and. death of our Saviour,
that Pope Gregory XIII. was led to make what is known as the second correc-
tion of the Roman calendar. He directed ten days to be dropped that year
(1582) from the computation, so that the 5th of October should be counted as
the 15th. He estimated the overplus of time reckoned at a little over eleven
minutes per year, or 18 hours 37 minutes and 10 seconds in a century, making
one day every 134 years, or nearly three days in four centuries.

To prevent a recurrence of the error in future he directed that the intercalary
day should be omitted three times in every 400 years, viz., in every centenary
year whose number could not be divided by 4 without a remainder (as 1700,
1800, 1900, 2100, &c), but added in the others (as 1600, 2000, 2400). This ar-
rangement was made upon the presumption that it was an exact equivalent for
the difference of time between the Julian and the solar year. And as the dif-
ference was estimated in Pope Gregory's day at 11 minutes annually, it was
a close approximate to such an equivalent, making almost one day in 134 years,
which varied but little from three days in 400 years. More accurate calcula-
tions, however, have since determined the time to be 11 minutes 14£ seconds,
Which makes a day in 128 years, or three days in 384, leaving sixteen years in
four centuries unnaccounted for. The Gregorian method of computation,
although not absoluely exact, is perhaps as near the truth as any that can be
devised which would be equally convenient for use.

The amended calendar, known as the Gregorian computation or " new style,"
was promptly adopted in all Catholic countries, but was pertinaciously resisted
by all Protestant governments. Up to the middle of the last century the Julian
reckoning, or "old style," was retained in all legal proceedings throughout Great
Britain and her American colonies.

Although the acceptance of the first of January as the beginning of the year
was pretty general, yet the ancient Jewish year, which began on the 25th of
March, continued to have a legal position in many Christian countries down
to within a few centuries. This was also "Lady Day," or the day of the " An-
nunciation of the Virgin Mary," when, according to the traditions of the Catho-
lic Church, her miraculous conception of the " Son of God," foretold in Luke i.
31 — 35, is said to have taken place. In all dates of an individual character, or
as attached to literary productions, it was left entirely optional with the authors
to use either the old or new style.

This want of a fixed system in the beginning of the year caused great per-
plexity, and often left the reader in doubt, when the months of January and
February were mentioned, whether they had been reckoned at the close or the
beginning of the year. From the necessities of the case a kind of formula of
double-dating grew into practice to express the old or new style ; but as it was
not universally adopted, it was of but limited practical advantage. The mode
was this: During the months of January and February, and to the 24th of

March, the year was stated thus, 1720-21, or 17§ j, meaning that by the ancient

194 INOCULATION IN MASSACHUSETTS.

mode of calculating the month belonged to 1720, hut by the new to 1721. After
the 25th of March there was no difficulty, for Toy both calculations the succeed-
ing months belonged to the new year.

By an act of the British Parliament, passed in 1751, it was ordained that after
December 31, 1751, each year in all her dominions should begin with January
1st instead of March 25th, as had been the custom and the law for generations,
and at the same time it was directed that 11 days be dropped from the calendar
of 1752, by enumerating the day that should follow September 2d of that year
as September 14th, and in all other respects adopting the Gregorian mode of
computation. It will be observed that 11 days had to be added when the new
style was adopted in Great Britain, while but 10 were added when the Julian
system was first amended. The reason of this is explained in the arrangement
for the disposing of the centenary intercalary days.

Gen. Washington was born February 11, 1732, old style. Great Britain, in
carrying forward the calendar 11 days, makes it jiecessary, in expressing this
auspicious occurrence under the new style, to add the 11 days, which gives us
Feb. 22d. To give the application of the Gregorian rule to a period anterior to
the adoption of the correction of the calendar, or when the difference between
the Julian and solar year had amounted to 10 days, we will take the discovery
of America, which dates from the discovery of St. Salvadore, one of the Baha-
mas, by Columbus. This appears to have been October 12, 1492, old style, or
October 21, 1492, new style, the difference between the calendars at that period
being but nine days.

France took the lead in fixing by law the 1st of January as the initial day of
the year, as well as adopting the new style, which she did in 1534, some years
previous to the promulgation of the Gregorian decree upon the subject. The
measure was adopted in different countries at various dates.

The new style was adopted in Italy and the Pontifical States in 1582 ; in
Scotland it was adopted by a decree in privy council by James VI. in 1600 ; in
Holland and Protestant Germany in 1700 ; and in Sweden in 1753. Russia
alone, of all Christian countries, retains the Julian computation, without having
adopted any means to correct the difference between the time reckoned and the
exact solar year. With her the intercalary day has been twice added, viz., in
1700 and 1800, while it has been omitted in all countries adopting the new style-
Therefore to bring Russian dates during this century into conformity with our
own, 12 days have to be added ; and after 1900, unless she sooner makes a
change in her computation, 13 will have to be added.

Great Britain retains the old style in computing her Treasury accounts. Her
Christmas dividends, therefore, do not fall due for twelve days after. The
Chancellor of the Exchequer also begins his year on the 25th of March. The
consequence is, the year with him practically begins and ends on the 5th of April.

Note 14. (Page 158.)

A singular though considerate regulation existed from an early period of the
settlement of Massachusetts with regard to funerals of persons dying of small-
pox. The constable was required by law to attend all such funerals. The order
reads thus : "Ye funeralls of any y» dy of ye smallpox and walk before ye corps
to give notice to any y* may be in danger of ye infection."

NOTES. 195

Note 15. (Page 158.)

In Great Britain, from the commencement of the practice of inoculation to the
close of the year 1728 — that is to say, during seven years — there were hut 897
persons inoculated, and out of this number 17 are set down as having died,
which is 1 death to every 52 persons inoculated.

Note 16. (Page 159.)

The records of the town of Scituate for the year 1721 show that her citizens
in town meeting determined, owing to the unparalleled suffering among the
poor in Boston, caused by the long continuance of epidemic smallpox, to send
£60 for then relief. Dean, in his History of Scituate, p. 112, gives an extract
from the town records as follows : " The town, considering the distressing cir-
cumstances of the poor people of the town of Boston, by reason of the present
sickness of smallpox, agreed to advance the sum of £60 in bills of credit, to be
sent to Col. Samuel Chickley, Mr. Daniel Oliver and Deacon Samuel Marshall,
to be distributed for the relief of the poor."

Note 17. (Page 160.)

See Woodville's History of Inoculation, p. 120, where he says : " Before I dis-
miss Dr. Boylston's pamphlet, it may be proper to remark that he seems to have
had discernment enough to discover that the smallpox as casually received is
much longer in taking effect than when communicated in the way of inocula-
tion, and that the latter supersedes the former by four or five days, a discovery
of which a more modern inoculator has taken the credit."

Note 18. (Page 164.)

The following passage will serve to show the style and temper in which the
controversy was conducted :

" To our amazement we find a notorious, scandalous paper, called the " Cou-
rant," full freighted with nonsense, unmanliness, raillery, profaneness, immo-
rality, arrogance, calumnies, lies, contradictions, and what not, all tending to
quarrels and divisions, and to debauch and corrupt the minds and manners of
New England. And what likewise troubles us is, that it goes current among
the people that the practitioners of medicine in Boston (who exert themselves in
discovering the evil of inoculation and its tendencies — several of whom we know
to be gentlemen of birth, education, probity, and good manners) are said,
esteemed, and reputed to be the authors of that flagitious and wicked paper."

196 INOCULATION IN MASSACHUSETTS.

Note 19. (Page 165.)

This order was worded in the roundabout diction of the time, as follows :
" That whosoever shall come into this town of Boston from any other townpre-
sumtuously, to bring the smallpox on him or herself, or be inoculated, shall
forthwith be sent to the hospital or pest-house, unless they see cause to depart
to their own homes. Or if any person be found in the town under that operation,
which may be an occasion of continuing a malignant infection and increasing it
among us, that they be removed immediately, lest, by allowing this practice, the
town be made an hospital for that which may prove worse than the smallpox,
which hath already put so many into mourning. And that the Justices and
Selectmen be desired to put the method above said into practice without delay
as the law directs."

Note 20. (Page 165.)

The "News Letter" of Nov. 21, 1721, gives the incident in the following
language :

"At the house of the Rev. Dr. Cotton Mather there lodged his kinsman, a
worthy minister, under the smallpox, received and managed in the way of
inoculation. Towards three o'clock in the night, as it grew towards the morn-
ing of Tuesday, the 14th of this instant, November, some unknown hand threw
a fired grenade into the chamber of the sick gentleman, the weight whereof alone,
if it had fallen upon the head of the patient (which it seemed aimed at), would
have been enough to have done part of the business designed. But the grenade
was charged with combustible matter, and in such a manner that upon its going
off it must probably have killed all the persons in the room, and would have
certainly fired the chamber and soon laid the house in ashes, which has appear-
ed incontestable to them that have since examined it. But the merciful provi-
dence of God so ordered it that the grenade, in passing through the window,
had, by the iron in the middle of the casement, such a turn given to it that in
falling on the floor the fired [ignited] wildfire in the fuze was silently shaken
out some distance from the shell, and burned out upon the floor without firing
the grenade. When the grenade was taken up there was found a paper so tied
with thread about the fuze that it might outlive the breaking of the shell,
whereon were these words : ' Cotton Mather, I was one of your meeting ; but

the cursed lie you told of (you know who) made me leave you, you

dog. And, damn you ! I will inoculate you with this — with a pox to you ! ' " —
(See Buckingham's Newspaper Literature, vol. 1, p. 23.)

Note 21. (Page 167.)

-■
': First. About twenty-five years ago I was at Cremona, in Italy, in the

French army, when there were thirteen soldiers upon whom this operation was

performed, of which operation four died ; six recovered, with abundance of

trouble and care, being seized with parotidal tumors, and a large inflammation

NOTES. 197

in the throat of one of them was opened ; his diaphragm was found livid, the
glands of the pancras tumified, and the caul gangrened. On the other the
operation had no effect.

" Second. In the year 1701, being in Flanders, there was committed to my
care, by M. le Due de Geirche, Colonel of Dragoons, one Captain Hassart, taken
ill of the smallpox, who told me in these very words : ' Ten years ago I was
inoculated five or six times without that cursed invention taking effect upon
me ; must I then perish ? ' He was so violently seized that he had several
ulcers upon his body, especially one upon his arm, which occasioned a lameness
thereof for fife.

" Third. At the battle of Almanza, in Spain, the smallpox being in the army,
two Muscovite soldiers had the operation performed upon them. One recovered,
the other received no impression, but six weeks thereafter was seized with a
frenzy and swelled all over his body. They, not calling to mind that the opera-
tion had been performed upon him, believed he was poisoned. It was ordered
by Helvetius, Physician to his Royal Highness the Duke of Orleans, Don Lo-
rencco Bollatio, and Don Bentura Barrera, two of the King of Spain's physi-
cians, that the body should be opened. His lungs were found ulcerated ; from
whence they concluded that it was the effect of that corruption which, having
infected the lymphce, did throw itself upon that vital part which occasioned
his sudden death."

Dr. Lawrence Dalhonde, Boston.

Note 22. (Page 167.)

Dr. TVoodville, in his History of Inoculation, says : " The New England
inoculation excited such attention that it was for awhile restrained by the strong
arai of the civil power, and the inoculator, Dr. Boylston, was persecuted with
the utmost malevolence." Thatcher, in his Medical Biography, speaking of
Dr. Boylston, says : " He underwent repeated examinations, and although he
invited all the practitioners in Boston to visit his patients and judge for them-
selves, he received only insults and threats in reply."

Note 23. (Page 168.)
Dr. Boylston says, in the preface to his Historical Account of Inoculation in
New England : " I have been basely used and treated by some who were ene-
mies to this method, and have suffered much in my reputation, and in my busi-
ness too, from the odium and reflections cast upon me for beginning and carry-
ing on this practice in New England."

Note 24. (Page 168.)

Among the prominent and influential friends who steadfastly adhered to Dr.
Boylston and the cause of inoculation, were the Rev. Increase Mather and his

198 INOCULATION IN MASSACHUSETTS.

son Cotton Mather, Rev. Mr. Colman, Rev. Mr. Cooper, Rev. Mr. "Williams,
and many other influential citizens. But these reverend gentlemen particularly
deserve well, for they exerted all the influence they possessed, both as ministers
and individuals, to recommend the measure to the public.

Note 25. (Page 168.)

The following is a specimen from one of the many which the inoculation
excitement produced :

" To spread abroad a mortal contagion, what is it hut to cast abroad arrows
and death ? If a man should wilfully throw a bomb into a town, bum a house,
or kill a man, ought he not to die ? I do not see how we can be excused from
great impiety herein, when ministers and people, with loud and strong cries, make
supplication to the Almighty God to avert the judgment of the smallpox, and
at the same time have been carrying about instruments of inoculation, and
bottles of the poisonous humors, to infect all who are willing to submit to it,
whereby we might as naturally expect the infection to spread as a man to break
his neck by casting himself headlong from the highest pinnacle. Can any man
infect a family in the town in the morning, and pray to God in the evening that
the distemper may not spread ? "

Note 26. (Page 168.)

The three following ministers published sermons in favor of the practice :
Rev. Increase Mather, Rev. Mr. Cooper, and Rev. Mr. 'Williams.

Note 27. (Page 168.)

Dr. Benjamin Franklin became an earnest and influential advocate of the
practice of inoculation, as I have noticed at some length in giving the history
of inoculation in Philadelphia.

Note 28. (Page 169.)

In the " Courant " of December 4, Franklin gives the following as a part of
the substance of the conversation : " Young man, you make it your business, in
the paper called the ' Courant,' to vilify and abuse the ministers of this town.
There are many curses which await those that do so. The Lord will smite
through the loins of them that rise up against the Levites. 1 would have you
consider of it. I have no more to say to you." Franklin defended himself
with ability, and showed that the citizens in town meeting were ready to pro-

NOTES.

199

^eed to extreme measures with the inoculators hut for his own cooler counsel
and that of a few others.

It was on this occasion that Franklin closed one of his notices of the minis-
ters with the following lines from a London paper :

" Thus P— sts, by strict rules,
May be called the edge-tools,
"Which the people, poor fools,

Are forbidden to touch •
Be a villain, a traitor,
Affront your Creator,
Or glory in satire,

It safer is, much ;
Nay, be lewd, drunk, or swear,
Proud, covetous, as they 're,
You may 'scape the holy snare ;
But if a P — st once you have thoroughly vext,
He '11 stick to you closer than e'er to his text,
You 're plagued for 't in this world, and d— d in the next."

Note 29. (Page 170.)

" But now, what is there to justify the virulent and unwearied endeavors of
these wicked men to make them (the ministers) odious ? The only pretext
they have is, that the ministers have intermeddled with civil affairs, and gone
out of their line ; and the only instance they can give of this (for the others are
only groundless surmises or open calumnies) is this : "When the smallpox was
first breaking out in the town, and every one foresaw and feared a dreadful
mortality, these good men were apprised of a safe method, which they hoped,
by the ordinary blessing of God, might be the instrument for saving many
lives. This method came to them with very authentic recommendations ; nor
was ever any remedy attended with a more uninterrupted and remarkable suc-
cess than this. This they communicated to the physicians, urging them (not
to put it into practice, as the ' News Letter ' declares, but) to meet together and
consult how far, or whether at all, it might be practised, and desiring they
would proceed with mutual assistance each to the other, as God should direct
them.

" And to do some justice, by the way, to that eminent person, the learned Dr.
Cotton Mather, Fellow of the Royal Society, who, to his honor, was the princi-
pal instrument in promoting this method among us ; and who now disdains to
draw his generous pen for his own vindication, against the many foolish pam-
phlets that are pointed at him, and who changes not his temper for all their
invidious calumnies. We will here transcribe the words with which he con-
cludes his address to the physicians, dated June 6, 1721 :

" ' I will only say (writes the doctor) that inasmuch as the practice of suffer-
ing and preventing the smallpox in the way of inoculation has never yet (as far
as I have heard) been introduced into our nation where there are so many that
would give great sums to have their lives insured from dangers of this dreadful
distemper, nor has ever any one in all America yet made the trial of it (though
we have several Africans among us, as I now find, who tried it in their own

200 INOCULATION IN MASSACHUSETTS.

country), I cannot but move it be warily proceeded in. I durst not yet engage
that the success of the trial here will be the same as it has hitherto been in the
other hemisphere ; but I am very confident no person would miscarry in it, but
what must most certainly have miscarried upon taking it the common way j and
I would humbly advise that it be never made but under the management of a
skilful physician, who will wisely prepare the body for it before he performs
the operation. Gentlemen, my request is that you would meet for a consulta-
tion upon this occasion, and to deliberate upon it, that whoever first begins this
practice (if you approve that it should be begun at all) may have the concur-
rence of his worthy brethren to fortify him in it.' Thus the Doctor.

" ~SVe appeal to the whole world whether this gentleman ' went out of his
line ' or did anything but what became a minister, a Christian, or a gentleman
in his address. And this is all the blame they do with any color charge upon
him, and which has given life to so many monstrous and bitter invectives
against him.

" But to return from this digression. The physicians never met nor consult-
ed about this method, according to the desires of the ministers, till one of them
began the experiment on his own family. He had just reason to apprehend
them in danger of being infected the common way. And here I cannot omit
to observe the happy juncture of affairs that united to render this his attempt
innocent and blameless. The worthy townsmen had taken the guards off the
infected houses, and in effect proclaimed the infection so prevalent that 't would
be in vain to strive to suppress it. By this act the nurses were commissioned to
ah' themselves, who had been stifled, for a considerable time, by a close con-
finement with the sick. Liberty was declared to them to walk the streets ; and
now, as the necessities of the sick urged, these infected persons might goto our
doctors upon any occasion, and any heedless or headstrong neighbors run in to
visit their contagious friends, which must necessarily render their families very
obnoxious to the distemper. This clearly evinces the imminency of the danger
his family was in ; and in a great measure vindicates his procedure. But, not-
withstanding, a mighty storm was raised and a libel published, which, among
other things, demanded an answer to a case of conscience. Six ministers of
Boston undertook to give a proper answer to the demand, wherein they did
some justice to the gentleman that that paper had unjustly reproached. After
this the ministers were silent for several months, till at length the constant suc-
cess of the experiment encouraged some of them to publish their sentiments
on this subject, especially what related to the case of conscience. And here we
think it very strange and ridiculous to see the satirists play the divine, and
deny that it falls under the cognizance of our ministers, when so many people
pretend conscience in the matter. This is to boast of their own divinity, as if they
were the only proper judges of what is the part of a divine, and to counterpoint
theh own skill and judgment to that of our famous professors. But we will
not ask who go ' out of theh line ' now. This is a full history of the crimes
charged on the ministers, wherein they have ' gone out of their line ' — that is to
say, when they saw their people dying about them, and the dearest friends
they had gasping for their breath, they did not cast off all bowels of compas-
sion and be content that no further trial should be made of a method that they
apprehended would deliver them from their clanger."

The title-page to the foregoing pamphlet reads as follows

NOTES. 201

" A Vindication of the Ministers of Boston from the Abuses and Scandals lately
cast upon them in divers Printed Papers by some of their People. Matt.
xxv. : 40 : 'Ye have done unto me.' Boston, in New England : Printed by
B. Green, for Samuel Gerrish. 1722."

Note 30. (Page 170.)
Drs. Roby and Thompson, whose successful cases of inoculation at Cam-
bridge and Roxbury are reported in Boylston's tables, early became advocates
of the practice. Dr. Nathan Williams, of Boston, who was esteemed an able
practitioner of medicine, as well as an eloquent and influential minister of the
gospel (a combination of professions very common in the early settlements of
the American colonies), adopted the practice. He also published a pamphlet
in defence of the practice of inoculation some time during the year 1721.

Note 31. (Page 175.)

Mr. Hutchinson died on the 30th of November, 1721 ; Mr. White died on the
10th of the following month. The Speaker, Mr. Clark, was a laborious physi-
cian, and it was supposed that in coming from the bedside of his patients suf-
fering with smallpox, he had brought the infection with him to the Court.
Hutchinson, in his History of Massachusetts Bay, p. 271, says, " The Speaker,
Mr. Clark, was one of the noted plrysicians in Boston, and, notwithstanding all
his care to cleanse himself from infection after visiting his patients, it was sup-
posed he brought the distemper to his brother members, which so terrified the
Court that after the report of his (Hutchinson's) being seized, it was not possi-
ble to keep them together, and the Governor found it necessary to prorogue
them."

Note 32. (Page 177.)

Dr. Douglas says there were no accurate statistics taken during or after this
epidemic, and we must therefore receive with some allowance his statement of
12 deaths among the 400 inoculated. It will be remembered that the ratio of
deaths among the inoculated in 1721, when the practice was entirely new, was
1 to 47, and there is no reason to believe that the practice made a worse exhibit
nine years later. But if we compare Dr. Douglas's estimate of the mortality
from inoculation in 1721, when he asserted it was one in every 14, we must
award him praise for his large liberality in placing the percentage nine years
later at 33. The Doctor was candid enough, in 1751, to acknowledge that in
1721 he was a tort of novice in the smallpox practice, and had confided too
much in Dr. Sydenham, an error which he had gradually corrected. — (See
Douglas's Summary, vol. ii. p. 394.)

202 INOCULATION IN MASSACHUSETTS.

Note 33. (Page 178.)

An act of the Legislature had been passed, and remained upon the statute
book late in the century, prohibiting inoculation. For when Dr. Benjamin
Gale, of Connecticut, wrote his " Memoirs of Inoculation in New England,"
which were published by the Royal Society, he complained of the embarrassing
effect of this law upon the people of Massachusetts. So far as I can discover,
Massachusetts was the only one of the American colonies that passed laws pro-
hibiting inoculation. Others, however, had laws regulating the practice. Her
seafaring men and youths residing in or resorting to seaports and large towns,
were by the nature of their business greatly exposed to the contagion of small-
pox, and having faith in the utility and safety of inoculation, were forced to go
to New York or Philadelphia, as they did in great numbers, to receive it in that
way. But these expert legislators finding that this law was evaded, and that
the people sought elsewhere the protection which inoculation afforded, passed
an additional act, with a severe penalty, prohibiting any person returning to the
colony within twenty days after he had left an inoculating hospital ; and, in
case another received the«disease from such, he should be made to pay treble
the expense incurred in consequence.

Note 33. (Page 180.)

The inoculating hospitals established in accordance with this grant are said
to have been the first for this purpose in the State. They were located in the
vicinity of Boston, and were opened to the public in 1764. One was erected on
Point Shirley by William Burnett, from New Jersey, and another at Castle
William by Samuel Giltson, from Nantucket. They were attended by Sylvester
Gardner, Nathaniel Perkins, Miles Whitworth, Jonas Lloyd, Joseph Warren
(afterwards General Warren), Benjamin Church, Thomas Bulfinch, and Joseph
Gardner. — (See Boston Gazette and Post Boy, 1764.)

Note 34. (Page 181.)

Professor Waterhouse observes, in a letter to Dr. Haygarth, dated October
28, 1788, that "There are perhaps 156 under inoculation at present, not one of
them paupers. They are principally children — perhaps thirty or forty of them
children of the first people of the Commonwealth. The charge of the whole
process is eight dollars, or thirty-six shillings sterling, including every expense,
from the incision to the dismission, which is usually three weeks. In some
places they inoculate for half that sum. You must conceive the whole of this
business conducted with a good deal of gayety, when the patient if ill is apt
to be pitied as if he were on a sailing party and sea-sick. Neither do I think
are the music and little ceremonies of parade totally useless. An established
system of mirth and good humor contributes not a little to their welfare."

NOTES. 203

Note 35. (Page 181.)

Felt, in his Annals of Salem, quotes from a paper of that day the following
notice in connection with the outrage : " On the 25th of the next month (Feb-
ruary) two men of the town, being suspected as concerned in the outrage, were
confined in our prison. In the evening a company of four or five hundred
persons from thence came to rescue the prisoners and carry them home. And
military companies are ordered to prevent this, but to no effect. March 1, by
command of the High Sheriff, his deputy assembles several hundreds of men with
arms, for recovering the two prisoners and seizing the principals concerned in
the rescue. In the meantime a large body are prepared at Marblehead to resist
this force. The proprietors of the consumed hospital, to prevent a collision
between these two parties, agree to give up the prosecution for damages." — (See
vol. ii. p. 435.)

Note 36. (Page 182.)

Marshall, in his Life of "Washington, after calling attention to the distressing
condition to which our army had been brought by the prevalence of smallpox,
says : "As the only effectual method of avoiding a return of the same evils the
ensuing campaign, the General determined to inoculate all the soldiers in the
American service. "With as much secresy as could be observed, preparations
were made to give the infection in camp, and the hospital physicians at Phila-
delphia Avere to carry all the Southern troops, who were for that purpose stopped
at that place and its neighborhood, as expeditiously as possible through the
disease. Similar orders were given to the physicians at other places ; and thus
was prepared for the ensuing campaign an army exempt from the fear of a
calamity which had at all times endangered the most important operations.
The process in camp was so conducted that no advantage of it was taken by
the enemy, and the example given in the army was fortunately followed very
generally throughout the country, so that this alarming disease in a great degree
ceased to be the terror of America." — (See Marshall's Washington, vol. iii. pp.
69, 70.)

Note 37. (Page 182.)

" The officers and soldiers of the American army were about this time (Janu-
ary, 1777) inoculated in their cantonments at Morristown. As very few of them
had ever had the smallpox, the inoculation was nearly universal. The disorder
had previously spread among them in the natural way, and proved mortal to
many; but after inoculation was introduced, though whole regiments were
inoculated in a day, there was little or no mortality from the smallpox, and the
disorder was so slight that from the beginning to the end of it there was not a
single day in which they could not, and, if called upon, would not, have turned
out and fought the British.

204 INOCULATION IN MASSACHUSETTS.

"To induce the inhabitants to accommodate officers and soldiers in their
houses while under the smallpox, they and their families were inoculated gratis
by the military surgeons. Thus in a short time the "whole army and the inha-
bitants in and near Morristown were subjected to the smallpox, and with very
little inconvenience to either."

Note 38. (Page 183.)

This law permitting hospitals for inoculation purposes to be built, caused one
to be erected in Watertown, another in Newtown, and also one in Medford and
Brookline. The latter place is scarcely three miles from Boston, and an equal
distance from Cambridge, where there was a similar institution. The chief
inoculating hospital of the State was the one at Brookline. ' This was under the
joint management of Drs. Isaac Bond, William Aspinwall and Samuel Hayward,
by whom more than three thousand persons were inoculated in one year, with
but very slight mortality. — (See Thatcher's History of Medicine, p. 23.)

Dr. Waterhouse says : " The buildings for inoculation are situated on a point
of land called Sewell's Point, which juts out into Charles river. This point is
not a bleak sandy beach, but ornamented with trees, pleasant walks, and green
banks, and is a mile and a half from the common road."

Inoculation had become so general in 1776-77-78 throughout the States that,
according to the reports of that day, scarcely four in a hundred of the male
population remained without protection. This fact was substantiated at the
yearly militia musters, where it was found to be fully verified on actual inquiry.
"Whether it would have been true among the whole population we cannot say,
but think it doubtful.

Note 39. (Page 183.)

Dr. Waterhouse, in alluding to the subject at a later day, says : " The inhabi-
tants of New England view the smallpox with singular dread ; not that they
ever suffered any remarkably desolating visitation from it, but the malady has
been kept at an awful distance by restrictive laws and still stronger popular
impressions, so that in New England, the most democratic region on the face of
the earth, the priest, the magistrate and the people have voluntarily submitted
to more restrictions and abridgments of liberty to secure themselves against
that terrific scourge than any absolute monarch could have enforced."

CASES

TEICHINA SPIRALIS IN SPRINGFIELD.

REPORTED BY

M. CALKINS, M.D.

OP SPRINGFIELD,

AND EUAD JUNE 5, 1867

CASES OF TRICHINA SPIRALIS.

In the family of Mr. Hall eight cases occurred which I
did not have the opportunity to investigate. Of these, one
died ; and, with others, I made a microscopic examination
of the portion of a muscle taken from the body of the de-
ceased. It was full of living trichinae. No complete autopsy
was permitted by the friends, and the small piece of muscle,
from the peronaeus longus, was obtained after much solicita-
tion by Dr. Gardner. These cases are reported in the
Medical and Surgical Reporter of May 4th, 1867, by the
family physician.

I have seen four cases in the later periods of the disease,
and have obtained the history of another from the attending
physician, Dr. W. W. Gardner, of this city. The infested
ham by which these cases were produced was examined by
several medical gentlemen, with magnifying powers varying
from 75 to 250 diameters, and found laden with the encysted
trichinae.

A brief history of the cases of which I have knowledge
may be of interest to the profession as illustrative of the
effects of a parasite which, until recently, has not been thor-
oughly studied. The first case, that of Mr. John Norton,
shows in a very marked degree the peculiarities of the dis-
ease, as they were communicated to me by the patient and
friends.

On the evening of Thursday, the 7th of March, about 9
o'clock, Mr. Norton ate four ounces — as nearly as he can

210 TRICHINA SPIRALIS.

estimate the quantity — of raw ham, afterwards proved to
have been laden with the parasite. About 3 o'clock in the
morning; he was attacked with severe pain in the stomach,
nausea, vomiting and diarrhoea, with a burning sensation
extending through the stomach and abdomen. The next
morning he took an active cathartic, and was able to attend
to light labor for about two hours in the Armory, but was
compelled to return to his house on account of the sickness
in the stomach and general indisposition. On Saturday he
attended to- light labor all day. On Sunday, occupied the
bed. On Monday, Tuesday and Wednesday, he attended to
his usual occupation, but with great difficulty. On Thursday,
the eighth day after eating the raw ham, he was so weak as
to necessitate the discontinuance of all labor. Medical aid
was sought, and an emetic prescribed, but the nature of the
case was not apprehended. On Friday, the ninth day, he
had severe distress in the epigastrium, extending more or
less over the abdomen, pain in the back, head and eyes, at-
tended with great muscular weakness. On Saturday, the
tenth day of the disease, the patient was no better. The
eyes were injected, and the lids and face oedematous, the
headache severe, cramps in the legs and arms, the slight-
est motion being followed by severe pain. The eyeballs felt
as if pressed full, with great difficulty in turning them from
side to side, and especially in turning them upward. There
was loss of power in the muscles of deglutition, difficult
mastication and stiffness in the muscles of the cervical region.
There was a burning or tingling sensation in the muscular
parts of the limbs and trunk of the body, also much dyspho-
ria. On Sunday, the eleventh day of the disease, he was
decidedly worse, and the muscular prostration very intense.
On Monday, the twelfth day, had less pain, but still more
prostrated. On Tuesday, the thirteenth clay, the renal se-
cretion passed freely. The pain was absent, but the extreme
muscular debility remained. On Wednesday, the fourteenth

TRICHINA SPIRALIS. 211

day, had no muscular power ; none on the fifteenth day. On
the sixteenth day could stand when the limbs were perpendi-
cular, but not otherwise. The respirations were rapid and
laborious. On Saturday, the seventeenth day, was able to
sit up and walk a few steps.

In three weeks after eating the infested ham the patient
returned to his labor, which was very light, requiring but
little muscular exertion. On the 15th of April, five weeks
from the time of eating the ham, the legs were cedematous,
the abdomen tympanitic, and the patient much harassed by
a watery diarrhoea, and suffered much from general muscular
debility.

It will be observed that this patient took an active cathar-
tic the next morning after eating the infested meat, which,
no doubt, carried off a portion of the parasites, and thus to
some extent modified the subsequent effects.

Case II. Miss Jennie Pattison, sister-in-law of Mr.
John Norton, ate, at the same time, of the same ham, about
an ounce, raw. Like the first case, she suffered from nausea,
diarrhoea, and gastric pain, on the next morning and during
the clay. On the seventh day after she was taken ill with
headache, fever, conjunctivitis, photophobia, oedema of the
eyelids and face, soreness and pain in the cervical and dor-
sal muscles, with soreness and cramps in the most muscular
parts of the limbs and trunk. Dyspnoea, dysphagia and
pharyngitis were also present. Being away from home
when attacked, the symptoms, especially the oedema, swelling
of the face and conjunctivitis, were thought to indicate the
accession of erysipelas. In from one to two weeks after
eating the infested ham the symptoms were most fully de-
veloped. On the fifth week after the introduction of the
parasite, the time of my seeing her, she suffered from gen-
eral muscular debility, oedema of the limbs, pharyngitis, and
anaemia.

212 TRICHINA SPIRALIS.

In this case the small amount of meat eaten did not pro-
duce the symptoms in a degree so marked as in the former
case.

Case III. Mr. William H. Gragg ate some two pounds
of infested raw ham in small portions, and at intervals, from
the 25th of February until the 7th of March. He gradually
grew ill, suffered from muscular pain, great muscular weak-
ness, inflammation of the eyes and lids. In two weeks after
eating the larger part of the raw infested ham, being a
portion of the same one from which the other cases had
eaten, he had severe pain in the muscles, especially in those
of the back and limbs, and eyes. Says his eyes at this time
felt as "hard as bullets," and that all rotary motion of them
was very painful and difficult. These symptoms, with the
usual variation, continued from the second until the six4h
week, when he still had great muscular debility, almost
verging on paralysis. On the eighth week after, he was able
to attend to his ordinary occupation, that of a tailor.

The gradual introduction of the parasite in this case modi-
fied the symptoms, by giving one brood time to become en-
cysted before another was developed from the immature
parasites introduced in the raw meat. Had the whole quan-
tity of ham eaten raw been introduced into the stomach
within two or three days, the result would, no doubt, been
much more serious, and, probably, fatal.

Case IY. Mr. S., on the night of the 7th of March,
while at the grocery store, was asked to taste, with a view
to ascertain its qualities, of a ham, from which another gen-
tleman wished to purchase a portion for his family. He cut
off a small piece — about an ounce — and ate it raw. In
about a week he became ill with the same symptoms as the
other cases presented. Dr. W. W. Gardner, the attending
physician, at first was suspicious that it was trichiuiasis.

TRICHINA SPIRALIS. 213

But the patient concealed the fact of his having eaten of the
infested ham. But subsequently it was proved by several
reliable witnesses; and, better still, by the acknowledgment
of the fact by the patient, that he had eaten of the same
infested raw meat that had caused the disease in others.
Dr. Gardner frankly told the patient, before he knew that
he had eaten of the infested meat, that he could not explain
the symptoms presented on any other hypothesis than that
of the existence of trichiniasis. He gradually recovered
his health, with the exception of suffering from muscular de-
bility.

Case Y. Mr. Fancher purchased from six to ten pounds
of the same ham from which Mr. Norton, Miss Pattison and
Dr. Gardner's patient ate. The largest part of it was boiled
and eaten without detriment by the family, but Mrs. Fancher
ate a small piece raw and quite a large amount imperfectly
broiled. The same result followed as in the other cases —
nausea, vomiting, diarrhoea, pains in the muscles, swelling of
the eyelids, photophobia, dysphagia, great muscular prostra-
tion, formication. After the fourth week she gradually im-
proved, but has suffered from muscular debility and diarrhoea.

The conclusions which may be inferred from these cases
are such as have been arrived at in other cases both in
Europe and America: that the parasite is destroyed by
thorough cooking ; that its effects are materially modified by
the quantity taken at one time ; that the slower the parasite
is introduced into the muscular tissues the less violent the
symptoms ; that the acme of the disease, when a large quan-
tity of the infested raw ham is eaten, occurs in about twelve
days ; that in from three to four weeks the severe symptoms
subside, the time at which the parasite becomes completely
encysted ; that the remote effects are largely due to injury
of the muscular tissues ; that the parasite does not cause a

214 TRICHINA SPIRALIS.

large mortality in those attacked, there having been in
Springfield thirteen cases and one death — a proportion very
nearly like that recorded as the result of the ^disease in
other parts of the world ; and that medical treatment is
useful in the first stage only so far as it can causae the ex-
pulsion or destruction of the parasites by emesis, catharsis
and anthelmintics ; and after the parasites have migrated into
the muscles, only so far as it can sustain the vital forces in
bearing the burden temporarily imposed upon them by the
presence of millions of organized beings, drawing their nu-
trition from the common source of supply to the muscular
tissues of the body.

THE LESSONS OF THE WAR

TO THE

MEDICAL PROFESSION.

By GEORGE DERBY, M.D.

SURGEON BOSTON CITT HOSPITAL. LATE BREVET LT.-COL. AND SURGEON U. S, VOLS.

READ JUNE 4, 1867.

THE LESSONS OF THE WAR TO THE MEDICAL

PROFESSION.

I propose, in the remarks which I have the honor to pre-
sent to the Massachusetts Medical Society, to review, as
briefly as possible, some of the points in which real additions
have been made to the knowledge of our profession by the
experience of the recent war. In so doing I will speak not
only of surgery, but will ask your attention to the means
employed for preserving the health of the army, and particu-
larly to the construction of hospitals. With your permis-
sion I will also refer, somewhat informally, to other matters
which, during four years service in the army, have come under
my observation, and which seem worthy of remembrance.
The surgical and medical history of the war, based upon
statistical data of the broadest and most complete character,
is now in active preparation at the office of the Surgeon
General in Washington, and will, at no very distant day, be
given to the world. Meanwhile, under the modest title of
Circular No. 6, we have already received an account of the
enormous mass of material which it will include, and have
learned some of the interesting results which are distinctly
foreshadowed. To these I shall refer as the highest
authority we have upon certain important questions. There
is also another class of subjects which cannot be reduced to
statistical form, and for these I must ask you to allow
me to give impressions and belief founded upon personal
observation.

218 MILITARY SURGERY AND HYGIENE.

I suppose the general feeling among those who, at the
beginning of the war, found themselves suddenly transform-
ed from civil practitioners into army surgeons, was something
like this : We will study Army Regulations and learn the
rules of the service as fast as possible ; establish friendly
relations with officers and men, and preserve their lives and
health by hygienic rules and counsel j avoid all unnecessary
operations, and by all means practise what we have learned
about conservative surgery to the utmost extent.

These anticipations were not all fulfilled. Fortunate was
the man who quietly submitted to the inexorable Regula-
tions, who tried no new and original plans for the execution
of his duties, and who did not vex his spirit and impair his
usefulness by scolding at reel tape.

Friendly and pleasant relations with officers and men are
completely in the power of the surgeon, and this for several
reasons.

First. Because no man knows but that his life may be
at the Doctor's disposal at any moment, whether he wills it
or not.

Second. Because, by the wise and admirable provisions
of the service, the medical officer has full and complete
authority, which not even the Commander-in-Chief may
gainsay, to excuse from duty, bv reason of sickness, any one
lie thinks proper.

Concerning the preservation of health by hygienic pre-
cautions, our most sanguine hopes were fulfilled. The
authority to mend abuses was not, as in the case of sickness,
absolute with the surgeon, and could only be exercised
through commanding officers ; yet, with a little care and dis-
cretion, it could almost always be freely exerted.

Of the practice of conservative surgery for gunshot injuries,
I can say in general terms that it led to disappointment. . So
far is it from being true that we amputated unnecessarily, I
believe the error, at least in the early period of the war,

MILITARY SURGERY AND HYGIENE. 219

was in the other direction. Immediate amputation in very-
many cases of broken limbs, which a vain attempt was made
to save, would have resulted in the preservation of life. I
say immediate and not primary amputation, and this is one
of those points which statistics do not make clear, since the
division is universally drawn between primary and second-
ary operations ; the period during which the former may be
practised including two or three days. The difference
between the chances of recovery of a man whose leg or arm
is amputated within an hour or two of his injury, and one
whose case is deferred twenty-four or forty-eight hours, even
although irritative fever has not been set up, I believe to be
very great. Why this is so, is not completely evident, but
of the fact I am well convinced. Perhaps the mental con-
dition may explain it, at least in part. A man who has been
hit in battle is in a state of mind to bear immediate opera-
tion, if the surgeon so- decrees. He is elated, proud of his
wound, surprised that he was not killed outright, and ready
for anything. The shock to the nervous system which we
observe in railroad accidents, and unexpected and inglorious
injuries, seems to be counteracted by this, state of mind, and
has never, within my observation, been a bar to immediate
action on the part of the surgeon at the field hospital.
Indeed, if the opportunity is then lost, it may in certain
cases never return. The next day, after a sleepless night,
the mental and bodily conditions are less favorable. If the
man passes the Division Hospital without operation, he ar-
rives in due time at the General Hospital, remote from the
field. Here the surgeons are less busy, and if the case is
one of broken thigh, or leg, or arm, it is, perhaps, amputa-
ted, or the attempt to make the splintered ends unite is con-
tinued. In either case the chance of recovery is far less
than if immediate amputation had been practised.

The results of conservative surgery, applied to fractures
of the femur, are thus given in Circular No. 6 : — Whole

220 MILITARY SURGERY AND HYGIENE.

number treated without amputation, 1761 : recovered, 321 j
died, 796; undetermined, 644. It will be observed that the
number of undetermined cases at the date of report (Nov.,
1865) is very large. The records of civil hospitals since
the close of the war show that many of the cases which had
seemed to terminate favorably have not in reality done so,
but have required frequent removal of dead bone. This is
not readily done ; in fact, it is a difficult and perilous pro-
cedure to remove portions of the shaft of the femur, and
when successfully accomplished is often discovered to be not
final and conclusive. The same trouble recurs, and after
repeated operations the patient has not infrequently died
after months and years of suffering. Cases of complete and
permanent recovery are certainly rare, and from the return
of the men to civil life their number cannot be definitely
fixed by the army reports. My own belief is, that in gun-
shot fracture of the femur, in either the lower or middle
third, immediate amputation should be the rule. In fractures
of the upper third it would depend upon the amount of com-
minution and the condition of the great vessels, but even
here, in a majority of cases, immediate amputation would, I
think, give the best chance for the preservation of life.
The same rule of immediate amputation is equally applica-
ble to gunshot injuries of the knee and ankle, and almost
equally so to fractures of the bones of the leg.

In gunshot fractures involving the shoulder joint, great and
positive additions to surgery have been made in the late war.
More than 800 cases have been treated by excision, and with
a less mortality than when amputation at the joint was prac-
tised. Up to November, 1865, 575 cases of excision of the
shoulder joint were reported : 252 primary, and 323 second-
ary. The mortality of the first was 23 per cent., of the
second 38 per cent. Since that date more than 200 addi-
tional cases have been reported. In the Crimea the French
army had 38, and the English 16 cases. Our surgeons have

MILITARY SURGERY AND HYGIENE. 221

demonstrated the advantages of this operation both in the
preservation of life and limb. That the arm is useful, we
have abundant evidence in the ability to write, and, indeed,
to use the hand with power and effect, which is now often
witnessed, and in the numerous photographs of the Army
Medical Museum. That subsequent operations for the re-
moval of dead bone are not unknown is certainly true, but
the same occurs after amputations, and the operation in the
case of the arm is usually neither difficult nor dangerous.

Of other excisions it may be generally stated that their
results have been less successful than those of the shoulder
joint. Of the wrist, very few were practised. Of the elbow,
315 cases are reported, with a somewhat greater mortality
than from amputations of the arm. Excisions of the knee
joint were seldom made, and the results were unfavorable.
In 32 instances excision of the head of the femur was prac-
tised, and in 4 cases recovery followed. When we remem-
ber that previous to our war only 12 instances of this
operation for gunshot wound were on record, and with but a
single recovery, the report of our surgeons may be regarded
as highly satisfactory. Of excisions in the continuity of the
long bones of the extremities, no favorable report can be
made. The mortality was greater than from amputations,
and this experience corresponds with that of recent Euro-
pean wars. Amputation at the hip joint was done 21 times,
and in three instances recovery followed.

Anaesthetics were universally used in our army ; chloro-
form alone in the field, as ether was too bulky and inflam-
mable for transportation. I have never known or heard of
an instance in which our surgeons had not a supply at hand
sufficient for all their needs.

Of the ambulance system I would say that, after many
trials and frequent failures, it was brought in the last two
years of the war to a condition very near perfection. No-
thing could be more admirable than the manner in which the

222 MILITARY SURGERY AND HYGIENE.

wounded were taken from where they fell to the field hospi-
tals, and thence, together with the sick, to the base hospitals,
in the Army of the Potomac in 1864. Officers and men
engaged in this special duty were of the bravest and best ;
picked men, proud of their department, and fully understand-
ing its peril to be equal to that of serving in the ranks. No
provisions which could then be suggested for the comfort
and safety of the wounded and sick were omitted. Such
provisions, however, were necessarily limited by the strength
and solidity of the ambulances required to pass over the
horrible roads.

In the recent European war a very simple arrangement
was used by the Prussian army, which seems to have been
never thought of in ours. Its usefulness is apparent on the
mere statement, and had it been suggested to the Surgeon
General I do not doubt it would have been at once adopted.
This is a system by which wounded men are ticketed by the
first surgeon into whose hands they may happen to come.
A card, stating the nature of the injury and signed by the
surgeon, is attached to the man's clothing. This plan would
have saved much time and suffering, as otherwise every
wounded man was liable to be examined unnecessarily.

The ability of both wounded and sick to bear transporta-
tion was a constant subject of surprise to our medical offi-
cers. Here again I cannot doubt that the mental condition
of the sufferers, who knew they were going to a place of
safety, combined with an abundant supply of fresh air, were
the influences which enabled them to bear with impunity
such hard usage as would, under other circumstances, have
been fatal. The inestimable value of an unlimited supply
of fresh air to our wounded and sick was, indeed, a subject
of daily observation. It often happened, for instance, that
a farm house and outbuildings were used for several days as
a temporary hospital. In these cases the occupants of the
piazza and horse sheds, and similar places, with only a shelter

MILITARY SUEGERY AND HYGIENE. 223

from the sky, did better than those who were provided for
within the house.

Let me ask your attention to another lesson of the war
which seems to me well worthy of remembrance. We have,
unhappily, evidence enough in our homes of the loss of life
among those who served in the army. But there is another
view of the subject equally striking and instructive, in which
our profession may feel a just pride. I refer to the number
of those who have been saved from death by disease through
a hygienic system which the spirit of the age, the enlightened
and generous provision of the Government, and the watchful
and constant care of the Medical Department, have conspired
to create and keep alive. The idea of war generally enter-
tained in times of peace has been of a succession of com-
bats, and of men killed and wounded. No very distinct
perception seems to have been had before our great struggle,
or perhaps, I should say, until the close of the Crimean war,
of the possibility of warding off epidemics, and of anticipat-
ing and averting the attacks of disease which all experience
has shown to be far more destructive to armies than the fire
of the enemy. Of the wars of the first Napoleon we know
on this point only that the losses by disease were enormous.
It was not the policy of rulers in those days to tell the world
how many men they sacrificed, nor was sanitary science at
all understood. In our Mexican war between 10 and 11
per cent, of the force engaged died annually from disease.
The Allies in the Crimea lost at least 25 per cent, annually
by disease. In our recent war the loss by disease in the first
year was 49 in a thousand. In the second year, 65 in a
thousand. In the third and fourth year the ratio is reported
by the Surgeon General's office as not greater than in the
first and second. The records are not yet completely ana-
lyzed, but enough is known to warrant this statement. We
have, then, an annual loss of about six per cent, by disease,
and this while campaigning in a country full of malarious
29

224: MILITARY SURGERY AND HYGIENE.

influences; and where fever is as rife among the inhabitants
as anywhere within the boundaries of the United States. It
will be seen at once that had our deaths from disease been
in the ratio which previous experience had given as the rule
of war, their number in four years would have been appal-
ling. It can be no exaggeration to say that the number of
lives preserved — lives which, according to the usual mortal-
ity of war; would have been sacrificed — was greater than
the whole number of lives lost both by disease and battle.

Looking at these facts as medical men, we find them not
accidental, but the direct and logical consequence of the
rules of hygienic science as applied to war. The military
necessity which compelled our armies to be in constant move-
ment, and which kept them for the most part in the open
country and away from large towns, had much to do with
their exemption from epidemics, as well as from syphilis and
other diseases which follow the excesses to which soldiers
are prone ; but these influences alone could never produce
such results. What has been done, and is now doing suc-
cessfully in the great cities of Europe to diminish disease and
prolong life, has bee.- even more successfully practised, and
for the first time in military history, for armies in the field.
Good and sufficient clothing, clean and well drained camps,
abundant food and plenty of coffee, unlimited exposure to
sun and air, and hospitals perfectly ventilated, have pro-
duced their legitimate results. To the attainment of these
great ends, all departments of the Government have contri-
buted, but the Medical Department first and chiefly. The
neatness of our camps might indeed give a useful hint to
Massachusetts farmers whose sinks, house drains, privies
and adjacent premises would often be the better for such
"policing" as a Medical Inspector would require for a
soldier's quarters, and no one can doubt that the family
health would be correspondingly improved. Other things
being equal, it was found in our army that the regiments

MILITARY SURGERY AND HYGIENE. 225

best disciplined, whose officers and men were most proud of
their neatness and order, whose camps were cleanest, and
whose cooking utensils were brightest, were most free from
disease.

In the early period of the war, the only hospitals known
in our army beyond the tents provided for regiments grew
out of the necessities of the case. No large provision was
made for the shelter of the sick and wounded. Conse-
quently all sorts of expedients were improvised by medical
officers under the authority of local commanders. In this
way houses, barns, churches and warehouses came to be used
as hospitals. Where lumber was attainable, rude and tem-
porary buildings were put together in s ich form as the sur-
geons desired. Hence a great number of models were
furnished for comparison, and from these rude beginnings
grew, not from any single mind, but by the conjoined labor
and experience of the Medical Department, a plan of hospi-
tal construction more extensive and far more perfect than
had before been known, and which, when its usefulness was
proved, was adopted by the War Department and required
to be exclusively used by medical officers. The value of this
experience in hospital construction seems to be inestimable
in civil as well as military service, and I desire to bring to
your notice the distinctive features of a plan which combines
in the simplest form all that is necessary, and, I am almost
inclined to say, as much as is useful, for the proper care of
the sick when brought together in large numbers for medical
and surgical treatment. The foundation stone of this plan
is the supply, under all circumstances, in summer and winter,
in all kinds of weather, and by the simplest possible means,
of an abundant supply of fresh air. The second great prin-
ciple involved is the separation of different parts of the
hospital, so that infection may not be carried from one ward
to another. All other details are unimportant and not es-
sential to the working of the plan. The first of these objects

226 MILITARY SURGERY AND HYGIENE.

is attained, in a way which I will presently describe, by
making the buildings used as wards one story high ; and no
deviation from this rule is possible. The wards are de-
tached and separate structures, and each at a distance of at
least thirty feet from any other. The length of these wards
may vary with the extent and shape of the ground to be oc-
cupied, but L shall give that which was ordered for the United
States General Hospitals. The other dimensions are fixed
and invariable. Length, 187 feet; width, 24 feet; height;
15 feet from floor to eaves, and 19 feet from floor to ridge.
The floor elevated 18 inches from the ground, with free ven-
tilation beneath it. A door at either end, and, if convenient,
one on either side also. Sixteen windows on each side. A
ward of this length contains sixty beds, with an allowance of
more than a thousand cubic feet of air space for each patient.
Ventilation is provided in summer and winter in the follow-
ing manner : — The ridge of the building is open in its whole
length, but provided with an outer cap or cover projecting
over the edges of the opening and raised a few inches above
it. This false ridge is provided with shutters, by which a
partial or complete closure can be made. Air is introduced
in summer through gratings in the floor, and by the windows
and doors, and finds free exit above in the whole length of
the building. In winter the shutters in the ridge are closed.
Air is then introduced through the gratings before mentioned,
directly over which are placed stoves, which may be of any
pattern fQr burning either wood or coal. Eight feet distant
from each stove is a vertical wooden shaft 18 inches square
passing through the roof, where it is properly capped, and
coming down to the level of the tie-beams, where it receives
the smoke pipe, which passes through its whole length. A
powerful upward current of air is thus produced. This
mode of ventilation has been tested in all the varieties of
climate which our country affords, from Maine to Louisiana,
and has been found perfectly efficient. The only modifica-

MILITARY SURGERY AND HYGIENE. 227

tion required by the extreme cold of New England is the
closure of the space beneath the wards, and the introduction
of air by horizontal shafts, as we supply our furnaces.

The wards are connected with each other, and with the
buildings used for cooking, washing, storage, and general
administration, by covered walks having floors but no sides.
A portion of either end of each ward may be partitioned off
for rooms for nurses, and for water-closets.

Never before have military hospitals been so free from
diseases generated within themselves as those just described.
They are now disused and demolished, but the lessons which
they teach, let us hope, will not be forgotten.

THE PATHOLOGY AND TREATMENT

VAGINAL CYSTOOELE.

By JOHN HOMANS, Jr., M.D.

OF BOSTON.

READ JUNE 4, 1867.

VAGINAL CYSTOCELE.

The name " Cystocele " is derived from two Greek words,
Kvaug} bladder, and Kyi?], tumor, and signifies a blad-
der-tumor. The affection is not a common one. Perhaps
the term cystocele ought to be restricted to those hernial
sacs, which, containing more or less of the parietes of the
bladder, push through some of the superjacent tissues.
Such herniae of the bladder occur at the abdominal ring, at
the crural arch, in the perinasum, and at the thyroid foramen,
being most common at the abdominal ring. There is another
condition of parts to which the term cystocele has been ap-
plied. It consists in a relaxation of the anterior wall of the
vagina, which permits the bladder to descend below its
normal anatomical level ; in this affection there is no real
hernia, no perforation of any ring, muscle, or canal. The
real pathological lesion is a prolapsus of the anterior wall
of the vagina ; but prolapse of the vaginal wall does not
necessarily convey the idea that the bladder is displaced,
and it is this displacement of the bladder that constitutes
the essential characteristic of vaginal cystocele. This con-
dition of the parts may be the result of many and severe
labors, during which the walls of the vagina may have been
greatly stretched, and have never afterwards recovered their
normal state of tension. Habitual over-distension of the
bladder may produce it. A violent cough often accompanies
and aggravates it, as does constipation also in almost every
instance. Laceration of the perinaeum may predispose to
30

232 VAGINAL CYSTOCELE.

it; the effect of the giving way of the posterior vaginal
wall being to throw too large a share of the weight of the
abdominal viscera upon the anterior wall. Too soon getting
up after delivery sometimes causes it. The pressure of the
child's head upon the vaginal wall, distended by a bladder
full of urine, might cause so much stretching of the tissues,
that a state of permanent relaxation, not only of the walls
of the vagina, but also of the attachments of the bladder,
may be the result, and this viscus, instead of remaining in
its normal anatomical position, behind the symphysis pubis,
may fall downwards in a greater or less degree, sometimes
distending the vagina and filling its outlet, sometimes pro-
truding between the external genitals. Of course the con-
stitutional effect of this state of things will vary with the
amount of prolapsus of the vagina and bladder, or of the
uterus, which is also often found to be prolapsed in cases of
cystocele. A slight bulging out would probably not cause
any great amount of disturbance, while such a state of re-
laxation as would permit the bladder (always covered by
the vaginal wall) to protrude beyond the external parts and
hang clown between the thighs, would cause almost ceaseless-
misery. A symptom first noticed by Sir Charles Mansfield
Clarke, and said to be very distressing, is a painful feeling
of dragging from the navel, probably to be explained by the
stretching of the remains of the hypogastric arteries, which
constitute in the adult the urachus, one of the anterior liga-
ments of the bladder.

Vaginal cystocele, if unrelieved, tends to grow worse as
time runs on. At first there may be only a slight bulging
downwards ; this allows a small cup- shaped portion of the
bladder' to be more dependent than the remaining floor of
the organ, and to form a reservoir for the accumulation of
urine ; at first this accumulation is small in amount, but gradu-
ally increases, and, by its weight, tends to drag the bladder
lower and lower, and make micturition more and more diffi-

VAGINAL CYSTOCELE. 233

cult. This may go on to such a degree that the bladder
cannot be emptied without first elevating the tumor ; the
meatus comes to be almost, if not quite, external to the labia,
and the course of the urethra, instead of being upwards
towards the posterior part of the pubes, is downwards and
backwards towards the perinaeum. A catheter, entering at
the meatus urinarius, passes downwards, and its beak is felt
near the fourchette ; or the urethra may be bent at a right
angle, and while the first half inch may be normal in its
direction, the rest of its course suddenly bends downwards,
dragged by the weight of the bladder, and the instrument
cannot be introduced without elevating the tumor.

The diagnosis of vaginal cystocele is not difficult From
a prolapsed uterus it can be distinguished by the absence of
the os tincse, and by the softer feel of the tumor ; the intro-
duction of the catheter would also settle the matter. From
an inverted uterus, and from prolapse of the posterior wall
of the vagina (rectocele), it can be distinguished by the
introduction of a catheter, which would settle, either that
the tumor was the bladder, or that the bladder occupied its
normal position.

The treatment of cystocele has for its object to restore
the bladder to its proper level, and to maintain it in its
normal position. Sir Charles Clarke recommends the wear-
ing of a hollow globular shaped pessary to support the
tumor, and the daily use of astringent injections, Bedford
recommends the use of a sponge pessary, or an India rubber
ball, and also advises astringent injections, and in some
cases a narrowing of the cavity of the vagina. Churchill
recommends astringent injections, and the use of a thick
wax candle as a pessary, or a roll of linen, or a hollow
curved pessary with its concavity towards the bladder.
" Marshall Hall (Baker Brown, Surgical Disease of Women)
recommended to remove a triangular slip of the mucous mem-
brane, the base being towards the orifice of the vagina, and

234 VAGINAL CYSTOCELE.

to bring the edges together by sutures, and thus to contract
the calibre of the vagina." Jobert (de Lamballe) (idem)
applied caustic around a more or less considerable oval
space on the posterior surface of the vagina, so as to form
an isolated spot, and repeated the application of the caustic
till the mucous membrane was destroyed. He then pared the
edges of the sore with scissors or a bistoury, drew them
together, and maintained them in apposition by means of
straight needles (the points of which were removed) and a
twisted suture. He operated thus on three patients with
success. Erichsen advises in some cases a plastic operation
for narrowing the vaginal orifice by lengthening the peri-
neum.

Mr. Baker Brown remarks (Surgical Diseases of Women,
p. 97), "Recognizing the prolapse of the bladder to be due
to the relaxation of the anterior wall of the vagina, I endea-
vor to remove this cause by a 'plastic' operation." The
operation recommended is as follows : The bowels having
been emptied, the patient is rendered insensible by chloro-
form, and put in the position for lithotomy, each leg being
held by an assistant, a third assistant holding up the tumor
with Jobert's bent speculum and pressing it under the pubes
into its natural position. A piece of mucous membrane,
about one inch long and three quarters of an inch broad, is
dissected off longitudinally from the vagina just within the
labia, the upper edge of the denuded part being on a level
with the meatus urinarius. The edges on each side the
vagina are drawn together by three interrupted sutures, and
then, at the next stage of the operation, the mucous mem-
brane is dissected off laterally and posteriorly, in the shape
of a horse shoe, the upper edge of the shoe commencing
half an inch below the lateral points of denudation, care
being taken to remove all the mucous membrane up to the
edge of the vagina, where the skin joins it. Two deep
sutures of twine are then introduced about an inch from the

VAGINAL CYSTOCELE. 235

margin of the left side of the vagina, and brought out at the
inner edge of the denuded surface of the same side, and
again introduced at the inner edge of the denuded surface
of the right side, and brought out an inch from its margin.
In this way the two vascular surfaces are brought together
and retained by means of quills, as in the operation for rup-
tured perinaeum. The edges of the new perinseum are lastly
united by interrupted sutures. Two grains of opium are
given directly, and one grain every six hours ; simple water
dressing. Beef tea and wine for diet. A catheter with an
elastic bag attached is kept in the bladder. Mr. Brown
recounts at length nine cases of cystocele treated by this
operation and cured, the subjects of the operations being
able to resume their duties in from three to six weeks.

Marion Sims (Uterine Surgery, p. 289), speaking of pro-
cidentia uteri, remarks : " It is the opinion of many that the
cervix uteri is the first in the order of exit, that it always
comes down, to open, like a wedge, the parts through which
the whole mass descends. I cannot say that this is not so
at first, but I can, with the greatest confidence, say that it is
not so in the great majority of cases when they become

chronic To observe the order of descent in a case

like this, reduce the parts to their normal relations, and let
the patient force them out again, whether in the erect posture
or on the back, and we shall see the anterior wall of the
vagina first forced downwards against the perineum, in the
form of a cystocele; " more force being used the cervix de-
scends, and the posterior wall of the vagina in the form of
a rectocele. The treatment for these cases of uterine dis-
placements complicated with cystocele, which Dr. Sims
recommends at present, properly finds its place among the
operations for the cure of prolapse of the anterior wall of
the vagina. Dr. Sims, previously to the year 1856, had
been in the habit of performing the perineal operation as
recommended by Mr. Baker Brown. This procedure was

236 VAGINAL CYSTOCELE.

not found successful, and Sims, having observed that when
the anterior wall of the vagina was pinched up into a longi-
tudinal fold, there was no protrusion of the bladder nor
uterus, conceived the idea of removing the redundant portion
of the anterior wall of the vagina. u I seriously proposed
to this lady," he writes, " to make a complete vesico-vaginal
fistula, by removing at once, as it were, a large portion of the
base of the bladder with the anterior wall of the vagina."

" Proposing to excise the anterior wall of the vagina,

I hooked it up with a tenaculum, pulled it well towards the
posterior wall, and then grasped the base of the mass thus
elevated with a pair of curved forceps, while with scissors I
removed at once a very large portion of the anterior wall of
the vagina." Luckily, Dr. Sims did not succeed in doing
what he had intended. For, instead of excising the base of
the bladder with the anterior wall of the vagina, he had
pinched up only the hypertrophied vaginal mucous membrane
in the forceps, and the bladder was uninjured. The raw
surfaces were united by silver sutures, and the cure was
complete.

Dr. Sims continued to operate in this way for two
years, and then, finding the bleeding from this large
denuded surface was great, and being unsuccessful in one
case, he invented another mode of operating. " Instead of
the broad scarification of the anterior wall of the vagina, I
simply removed the mucous membrane in the form of a V
(See Fig. I.), the apex being near the neck of the bladder,
and the two arms extending up on the sides of the cervix.
These two denuded surfaces were brought together by silver
sutures passed transversely, thus making a longitudinal fold,
narrowing the vagina and crowding the cervix backwards "
(leaving a pouch under the new septum).

Fig. I.

Marion Sims's operation for cure of prolapse of the uterus, a and b, arms of triangular flap
removed ; c, portion removed by Dr. Emmet in addition.

Fig. II.

Same modified and improved by the further denudation ate e d, practised by Dr. Marion Sims.

238

VAGINAL CYSTOCELE.

This operation was always successful ; but in September,
1862, one of the first patients operated on by Dr. Sims came
to consult Dr. Emmet on account of persistent tenesmus,
and it was found that the neck of the uterus had slipt behind
the septum into the pouch, the fundus of the uterus had been
thrown into the hollow of the sacrum and the organ was
firmly fixed. The neck was disengaged with difficulty, and
the tenesmus immediately relieved. To remedy this trouble,
which Dr. Emmet found had happened in other cases, he
(Dr. E.) removed the mucous membrane in a line across the
" cul de sac," between the two points at the base of the tri-
angle (Fig. II., e).

I cannot do better, perhaps, than show to the Society this
representation of a case of cystocele lately under my care.

The drawing is an exact copy of the appearances, and was
very kindly made for me by Mr. H. P. Quincy, late one of
the House Surgeons of the Massachusetts General Hospital.
The case here represented is that of Mrs. C. M., aged 42
years, married, mother of eight children, the youngest six

VAGINAL CYSTOCELE. 239

years old. Sixteen years since was confined with her first
child ; the presentation was by the foot or breech, and she
was without intelligent assistance for twelve hours, during
which time the labor lasted. Ever since her first confine-
ment she has suffered with dragging pain in the back, and
with difficulty of micturition ; there has been a tumor pro-
truding, much of the time, from between the external geni-
tals, thought to be a falling of the womb ; when this protru-
sion was large, there was dragging pain from the navel. On
examination, the state of things described above, and so well
figured in the accompanying sketch by Mr. Quincy, was found
to exist, and the course of the urethra was found to be
downwards ; there was very slight prolapsus uteri, the tumor
consisting of the anterior wall of the vagina, distended by
the bladder.

Operation, April 11, 1867. The bowels having been
previously emptied by a cathartic, the patient was etherized,
and the bladder emptied of water by the catheter. Dr.
Ropes, Dr. Lincoln and Mr. Quincy kindly assisted me. The
tumor was pressed up under the arch of the pubes, and held
there by a bent speculum. A piece of mucous membrane,
one inch and one quarter wide and two inches long, was dis-
sected off from each side of the vagina just within the labia,
the upper line of the incisions being on a level with the
meatus. On each side the raw surfaces were united by
superficial interrupted sutures of twine. A horse shoe
shaped piece of the same width was then dissected up from
the posterior sides of the vaginal outlet, and from the four-
chette. This dissection met those first made on each side,
so that, in fact, the mucous membrance, just within the labia,
was dissected up, for a width of about an inch and a quarter,
from a point opposite the meatus on one side, round to a
corresponding point on the other side. One of the assis-
tants then seized the fundus of the bladder and drew it
forcibly downwards outside the vagina. An elliptical shaped
31

240 VAGINAL CYSTOCELE.

piece of mucous membrane, two inches long by one inch
wide, was dissected off the anterior face of the tumor, i. e.r
the roof of the vagina. The edges of this incision were
united by interrupted sutures, as were also those of the pre-
viously described dissection. The perinasum, however, was
not lengthened, it being thought that the amount of contrac-
tion, resulting from the cicatrices of these different raw
surfaces, would be sufficient to effect the desired result.
This was a mistake, as will be seen subsequently. An
elastic catheter, having an India rubber tube attached, was
placed in the bladder, and a wet compress and bandage
applied. The operation lasted two and a half hours, and
the patient was under the full effects of ether during that
time. For the facility with which the operation was per-
formed I am wholly indebted to the assistance of the gentle-
men above named. Directions were given that the patient
should take a grain of opium every six hours.

April 13, Catheter changed. Yagina washed out with a
dilute solution of carbolic acid (a very valuable antiseptic).

April 16. Several stitches removed.

April 17. Catheter removed from bladder on account of
pain and irritation. Patient to pass her water every three
hours, resting on her hands and knees.

April 21. Wounds contracting finely. Tumor not pro-
truded on coughing.

April 24. Patient allowed to stand up ; tumor was not
protruded on coughing.

April 25. Patient, contrary to orders, strained violently
in an attempt to empty her bowels, and this morning the
tumor is hanging down in the vagina.

May 2. Patient allowed to go home. Vaginal outlet is
much narrowed. Tumor falls down somewhat, and will pro-
bably get larger as patient goes about. The wounds are
healed. An India rubber ball was given to her, an inch and
a half in diameter, and she was directed to wear this.

VAGINAL CYSTOCELE. 241

May 20. Patient states, " The ball has never come out;
and keeps the tumor up well? except when the water accu-
mulates in large quantities. I think if it was not for the
ball, it (the tumor) would come down as much as ever."

In the treatment of cystocele we have to choose between
some of the different methods above enumerated, or propose
something which will answer our purpose better. The object
to be attained in all methods is the same, namely, to keep
the bladder so supported in its normal position that it will
not become prolapsed. A recent and slight cystocele might
be relieved by rest in the recumbent position, frequent ca-
theterism and the use of astringent injections. A large and
troublesome case might be treated by means of pessaries, or
by operation. The choice of pessaries, or the method of
operating, must be determined by the individual peculiarities
of each case. A very good pessary is a roll of cotton wool }
India rubber balls and inflated India rubber bags are good.
When there is prolapse of the uterus (and this is a very
frequent accompaniment of cystocele, and, in many cases,
the cause of it) the operation either of Marion Sims, or that
of Baker Brown, seems to promise the best results j and of
these two operative proceedings I am inclined to give the
preference to that of Dr. Marion Sims as being the most
likely to give the required mechanical support. The opera-
tion of Mr. Baker Brown, thoroughly performed, would
prevent the cystocele from protruding, but not always from
filling the vagina.

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injurs to % pah-

By J. M. Harlow, M.D., Woburn.

das* of djtlcjs^

By M. G. Echeverria, M.D., N. York.

(Iril^eiit Surgrrjr,

By Buckminster Brown, M.D., Boston.
(With Photographs )

BOSTON :
DAVID CLAPP & SON 334 WASHINGTON STREET.

medical and surgical journal office.

18 6 8.

Session of 1867.

No. 5.

THE CONTAGIOUSNESS

CHOLERA.

By HENRY G. CLARK, M.D.;

OF BOSTON.

Read before the Society, June 4, 1867.

THE CONTAGIOUSNESS OF CHOLERA.

Mr. President and Gentlemen, — I purpose to consider to-day, as
well as I can in the brief space I feel at liberty to occupy, the
subject of the Contagiousness of Cholera. It is almost unnecessary
to say in this presence, that the doctrine of the contagiousness of
cholera has, of late, found a very considerable number of adherents
(some of them ardent and able), and that the examples, or the argu-
ments, of these enthusiastic, but as some of us believe mistaken advo-
cates, have been sufficiently influential to give to it such a degree of
credit or currency that, to a certain extent, it may be said to have
become fashionable. It has, at the same time, been quite distinctly
announced, by some of the advocates of this novel and hurtful doc-
trine of contagion, that all those who, in the absence of what they
deemed to be good and sufficient evidence of its truth, declined to give
it their adhesion and adopt it as their profession of faith, had fallen
behind the progressive and scientific spirit of the age ; and that,
standing as they were on the quicksands of a blind unbelief, they,
and their antiquated theories, must soon be swept away by the ad-
vancing tides of a more enlightened literature.

Among these unbelievers, after having, as I think, carefully taken
such observations as have enabled me to estimate " the situation,"
and its difficulties and perils as well as its inherent solidity and
strength, I must confess that I am, for one, quite content to stand.

I do not, of course, on this occasion, intend at all to enter upon a
general discussion — for that is obviously impossible — but simply to
make such suggestions *as I hope may induce those who are still in
doubt on so important a subject to examine for themselves the abun-
dant evidence relating to it which is now accessible to the profes-

246 CONTAGIOUSNESS OF CHOLERA.

sion ; and, if possible, to induce those who have adopted a belief which
very many of the best men in this and other countries, most tho-
roughly acquainted with cholera, believe to be an error, and founded
on insufficient reasoning and unproven premises, to revise their
opinions.

In order that there should be no misunderstanding in a case like
the present, it is only right that the terms used should be exactly
and clearly expressed. What, then, is " contagion " ? It is defined
by one of our best lexicographers* as " the communication of disease
from one person to another by contact, direct or indirect,* infection."

Punglison says that the terms •'•contagion and infection are gene-
rally deemed synonymous." Such, however, I do not understand to be
the generally received opinion in the profession. Contagion is best
defined to be* •• that quality of disease by which it is capable of
being communicated from one person to another by actual contact, or
which may be caught by a near approach,11 Infection is that quality
©f disease by which it is capable of being transmitted, by fotnites,
or by means of clothing, rags, wool, &c, to long distances from the
bodies of the sick, and which poisonous influences may be retained
in them for a very considerable length of time. In contagion, the
presence of the 'person is necessary, while in infection it is not.

Some contagious diseases, such as smallpox, are also infectious ;
others, such as parotitis and pertussis, are not. But infectious dis-
eases, on the other hand, are not always contagious ; yellow fever
being a notable example.

The earlier advocates of the contagious properties of cholera did
not hesitate honestly to use the word itself in the sense in which it
is here explained, adding sometimes, also, a credence in its infectious
qualities; but this plainness of speech, for some reason, has more
recently fallen into disuse, and the more flexible words " communi-
cable " and •• communicability " are its substitutes. These were
more generally applicable, and less easily brought within the well-
defined limits assigned to the words •• contagion," ••' contagiousness,"
" infection," &c, and may be made to convey^ as might be conveni-
ent, a great variet}7 of meanings; thus, for instance, an epidemic

* Webster, 4to, loc. cit.

CONTAGIOUSNESS OP CHOLERA. 247

which prevailed successively in variou%places on great routes of
travel, was said to have been "communicated" notwithstanding the
fact that it often happened that the densely populated villages radi-
ating from infected cities, and even intermediate cities, frequently
escaped. By some, the disease was said to be communicable through
the respiration ; by others, through the digestive organs, and each ex-
perimenter— for many experiments were made by injecting the veins,
the air-passages, and the stomachs of dogs by fluids from patients
affected with cholera — proving his own theories, and, at the same
time, effectually disproving the opposite theories of his rivals.

But, in the face of the astounding fact related of " Dr. Foy and
ten others, at Warsaw, who inoculated themselves with the blood of
cholera patients, tasted their dejections, and inhaled their breath,
without receiving the disease," we may safely say that the experi-
ments of Drs. Snow and Pettenkofer only prove, what everybody
knew before, that drinking of dirty water and breathing of a foul
air would be the most likely means to produce cholera, in a choleraic
season, in those who were thus exposed.

The most remarkable position, however, now taken with pretty
general unanimity is, that in whatever mode the materies morbi
finds its way into the body, the most efficient cause is found in the
choleraic dejections themselves. On this they are agreed ; but they
say, when confronted with all the facts which abound everywhere, of
constant and continuous exposure, and especially with such as that
related of Dr. Foy, " that the dejections themselves are not poison-
ous until they have become by time and exposure partially decomposed" !
One would imagine — if all these disagreeable conditions must be
complied with in order that cholera should be communicated, and
when coupled with the other aphorism (which some have promulga-
ted) that "no new cases originate unless from some other case ' —
it would spontaneously die out and disappear ! But such facts
fade into insignificance when we consider, as well stated by a
distinguished surgeon of the East India Company, " 1, That the
great numbers attacked simultaneously, and who had previously had
no intercourse with the sick, cannot be accounted for except by sup-
posing the disease to be simply epidemic ; and, 2, The general ex-

248 CONTAGIOUSNESS OF CHOLEEA.

einption from the disease of<medical and other attendants on cholera

cases."

In the opinion that Asiatic cholera is non-contagious we have the
almost unanimous concurrence of the East India surgeons, who al-
ways see it. We have also the often deliberately expressed judg-
ment of the General Board of Health of Great Britain. In this
connection, the resolution passed by the Westminster Medical So-
ciety (a most competent body) is worth quoting. Dr. Granville
moving, and Dr. James Johnson seconding the resolution, it was,
after the preamble stating the time, &c, devoted to the considera-
tion of the subject, passed in the following words : — " In the opinion
of the Society, the evidence brought forward to prove the said mala-
dy to be a contagious disease has signally failed; and that every
circumstance which has come to the knowledge of the Society shows
the disease to have begun, progressed, and ended in the ordinary
way of every epidemic disorder."

This opinion is confirmed and repeated by the experience of the
epidemic of 1854. Dr. Sutherland, one of the Board, says:- — UI
look upon the evidence oj the non-contagious character of cholera to be
perfectly conclusive."

The physicians at Moscow and St. Petersburgh generally subscribe
to the same opinion. Of that of the Consulting Physicians of this
city I need not speak, as it is well known.

Dr. Jacob Bigelow, for many years one of the Consulting Board,
and whose opinion will, I know, have with you the great weight
which should be accorded to the wisest of us all, writes as follows,
and the extract contains within itself a whole volume of wisdom: —
" No country, I believe, has succeeded in keeping out cholera by
quarantine, and no country, as far as we know, can produce it artifi-
cially, or retain it after the predisposition has disappeared. In its
own time it moves on thoroughfares where men are travelling, and
spreads in cities where they are stationary, for no better reason known
than that mankind are its necessary food, and that where there are
no people there can be no cholera. But why of two frequented
roads or cities it selects one and avoids the other, investigators have
not yet been able to satisfy us."

CONTAGIOUSNESS OF CHOLERA. 249

In the uncontradicted statements that cases of cholera have occa-
sionally occurred at the South all winter — in its late fatal loiterings
here the last season — in the simultaneous announcements to-day of
cases on the Mississippi; in London, and at Paris, we may see the
foreshadowing of the pestilence, which, at these distant outposts of
observation, gives us the necessary timely warning. It seems to be,
then, peculiarly appropriate that we should now turn our attention
to this doctrine, because a belief in the doctrine of contagion will
do much towards retrograding us to the obsolete systems of
quarantine.

When the*¥nembers of the medical profession, as a body, and with
them most heartily many non-medical sanitarians, have been making
the most strenuous and energetic efforts to mitigate the costliness
and hardships of quarantine, this unnecessary recurrence to the idea
of contagion of course goes far to encourage the restoration of
an evil we have all along been so anxiously striving to be rid of;
and to prevent us from reducing it to the milder forms in which
it would only be likely to exist under the requirements of modern
sanitary law.

By whom has this retrograde movement been inaugurated and pro-
moted ? As in all the former history of sanitary cordons, and of
rigid and useless quarantines, in times past; very much by the preju-
dices of non-professional functionaries — who, only taking counsel of
their fears, or, perhaps, misled by their interests, have used official
power ignorantly or mischievously.

Consular agents and secretaries of state, as such, know nothing of
sanitary laws ; and they take unwarrantable liberties in professional
matters when they undertake to advise for or against quarantines.

To conclude, in the words of the distinguished East India sur-
geon whom I have already quoted, " It is by both houses conceded
that if cholera is contagious, the most rigid quarantines that sagacity
and experience can devise, and firmness enforce, are imperatively
demanded for the protection of populations ; and, that if, on the other
hand, it is not contagious, such quarantines are not only useless but
infinitely pernicious, by their tendency to plunge in extreme misery
the hundreds of families and thousands of individuals who are de-

250 CONTAGIOUSNESS OF CHOLERA.

pendent upon the commerce they suddenly blockade, and the labor
they suddenly discharge ; and so to encourage those conditions which
most potently invite the disease, while, at the same time, they fright-
en off the humaner agencies which alone can prevent, conquer, or miti-
gate it ; therefore, we prefer to take this question sharply by the
throat, and to declare our positive conclusion, deliberately reached,
through careful examination and comparison of all the evidence
brought forward on both sides, as well as from unusual opportuni-
ties in the very laboratories and hot-beds of this atmospheric poison,
that not a single case — well attested, and clearly, completely demon-
strated— of cholera transmitted by contact alone wiwthe person,
clothing, excretions or effluvia of another case, has ever yet been cited ;
and this we say in the full knowledge of all the quasi ' facts and
proofs' elaborated by the glorious minority of contagionists, whose
doctrine manifestly tends, first, to make victims, and then, to leave
them prostrate and unbefriended — for panic nurses cholera, and the
Doctrine of Contagion Patronizes Panic."

MODERN SURGERY.

By E. M. HODGES, M.D.

OF BOSTON.

READ JUNE 2, 1868,

MODEM SURGERY.

The celebrated Traite des Maladies Chirurgicales of
Boyer was published in 1814, and the eminent author wrote
at the beginning of his preface, that " Surgery appeared to
have reached, or very nearly so, the highest perfection of
which it seemed capable."

Fifty years and upward have elapsed since then ; yet who
would now dare to assert himself qualified to compose a
perfect and faithful history of Surgery, to delineate with
truth and impartiality the present state of that science j
borrowing from all the centres whence its doctrines are
diffused, in all the countries where it is successfully culti-
vated ?

Modern surgical pathology embraces a range of study
beyond any one man's comprehension. Limited but by the
means and method of observation, it obliges the most stu-
dious investigation of details and expects the broadest
philosophic generalization.

In reviewing the actual state of surgical knowledge, it
will be found that its great advancement in our generation
is due to the unlooked-for extension, in these latter years, of
the sciences to which Pathology naturally turns for assistance.
It is this which has given it a progressive tendency and
stamped its existing condition with at least three character-
istics. These are — 1st, Precision of Observation; 2d, Per-
fection of Diagnosis ; 3d, Simplification of Treatment and
reluctant resort to Operation.

254 MODERN SURGERY.

Precision of Observation as applied to the methodical
study of surgical cases and the results of operations, consti-
tutes almost a science in itself. Conducted or facilitated
by the aid of more and more perfect instrumentalities, the
perceptive faculties are distorted by fewer preconceived
ideas ; the mind, educated to exactness, discountenances what
is merely traditionary, and rejects that form of argumenta-
tion either in thinking or speaking, which takes for granted
what ought to be proved.

Surgery is not an exact science. As regards no one
point, therefore, can the need of examiuation cease, or its
frequent repetition be carried too far. The observation of a
single individual cannot be compared to the experience of
many, and the study of current surgical literature is the only
means by which this experience can be assimilated. A
knowledge of disease resting on description alone is, however,
of little avail, unless researches already made are con-
firmed afresh by renewed and reiterated investigation ;
by the analysis of facts in large numbers a nearer approxi-
mation to truth and better practical conclusions are made
possible. It is more and more a feature of modern surgical
authorship that its statements are not gathered from scat-
tered sources, but are the fruit of individual observation.
It is the aim of this observation to see phenomena as they
really are ; to analyze these phenomena, compare and classify
them, and from these data to build a theory or reason for
their existence ; and so to comprehend the etiology and
control the development of disease, as well as to foresee and
arrest complications which the most skilled hands and in-
genious devices have hitherto been powerless to prevent.

For instance, the ideas prevailing with regard to septse-
mic poisoning and the pathological views emanating there-
from, owe their existence to repeated observation, by
methods increasing in precision, of the consequences which

MODERN SURGERY. 255

follow alterations in the normal condition of the natural
fluids of the body, alterations to a great extent produced by
external causes, more or less amenable to control. The
study of Hygiene is largely occupied with these researches.
They engage the attention of surgeons of our own day more
than any one subject, and have tended in a degree not suf-
ficiently realized, to modify the aspect of modern surgery.

The practical conclusions arrived at by such observa-
tion have taught us that an injudicious diet, or mode of
dressing wounds, is as pernicious in its influence on the
blood or the secretions as a vitiated atmosphere ; that the
fear of traumatic fever need no longer proscribe animal
food or alcohol to the subjects of wounds or operations ;
that it is for the interest of the patient as well as to the
advantage of the surgeon, that dressings should be reduced
to their simplest proportions. Indeed, the disuse of cerates
and ointments, of fenestrated lint and charpie with its fan-
tastic shapes, of bandaging and plasters, together with
setons, issues and the lancet, has robbed minor surgery of
its attractions, and simplified it almost out of date.

Between the two periods of 1836 to 1841, and of 1850
to 1861, the mortality of amputations in the Paris Hospitals
diminished twenty (20) per cent.; though no single cause
can be alleged in explanation, every one recognizes that the
lives thus saved are a consequence of improved Hospital
administration. The unequalled success of surgery in our
recent war was confessedly due to the enlightened judgment
which demanded the hygienic surroundings and attention to
executive detail that so generally prevailed in army hospitals
wherever established.

The anxiety to diminish opportunities for the entrance
into the economy of poisonous emanations which distinguishes
surgical treatment at the present day, has gone so far as to
encourage attempts to supplant cutting instruments by the,

256 MODERN SURGERY.

at least; doubtful expedients of the ecraseur and the terrible
osteoclaste, and by the pernicious use of caustics or other
agents which exercise a coagulating influence on the organic
tissues and fluids. On similar theoretical grounds, acupres-
sure, instead of the ligature of arteries, drainage tubes to
evacuate cavities containing purulent matter, and carbolic
acid as a dressing competent not merely to disinfect wounds
but in fact to avert inflammation, have been largely tested by
experiment. Although the merit of neither of these latter
methods has yet been determined, or if determined has
received an unfavorable verdict, the direction of thought
which these suggestions indicate attracts the attention of
surgeons. The restlessness which such endeavors betray,
while it disturbs conservative equanimity, is evidence of a
watchful, though not always judicious activity to promote
safer and surer methods of surgical treatment.

Perfection of Diagnosis, the second of the three characteris-
tics I have mentioned, is an important aim ' of modern sur-
gical inquiry.

Anaesthesia, chemistry, physics, with the microscope, op-
tics, and electricity, experimental physiology, statistical and
historical research, criticism in learned societies, have each
in turn contributed to this end. The basis of all diagnosis,
however, is founded upon exact anatomical knowledge, of
healthy as well as morbid structures.

The habit of comparing what we observe in living
patients and can see in the dead subject, has long per-
mitted surgeons to recognize the mechanical and physical
influences upon surgical disease which spring from the struc-
tural arrangement of the human body, from the relationship,
density, resistance, permeability and elasticity of the tissues.
Twice Velpeau diagnosticated a peri-anal abscess as having
its starting point at the base of the skull, between the

MODERN SURGERY. 251

pharynx and the articulation of the atlas with the occipital
bone. The route of urinary and purulent infiltrations may
be anticipated by less skilled diagnosticians.

If the limit to which anatomical investigation by the
scalpel can be carried has been reached, tha.t attainable by
the microscope is far from being approximated. Indeed,
topographical anatomy, less than fifty years old, has lost its
distinctive character; the requisitions of modern surgery
demand, as something more than a mere accomplishment,
knowledge, not of a few regions or triangles, but of the
whole body even to its elemental structure ; and Virchow has
already shown that the fundamental elements control and
modify the characteristic growth and material individuali-
ties of a tumor, in a manner not less than the constituent
parts in the midst of which it is developed influence the
form and contour of the whole mass.

But mere diagnosis of the existing ailment, however pre-
cise, does not satisfy the demands of an observation stimu-
lated by existing means of exploration.

In all our clinical studies there prevails the constant effort
to make out an individual and specific cause for every diag-
nosticated disease. Though this aim is imperfectly realized,
negative results, not without value, have been frequently
reached.

We have learned within the last few years that pyaemia,
erysipelas and malignant pustule are something more than
simple inflammations. Certain paralyses and neuralgias are
now known to be excited through reflex action, by lesions
remote from the great nervous centres. Newly recognized
and peculiar features stamp the increasing number of
sequelae which syphilis is found to occasion, as, for example,
the syphilitic teeth and cornea described by Mr. Hutchinson,
and the evidences of this disease in internal organs indicated
by Mr. Wilks. Experimental physiology shows us that the

258 MODERN SURGERY.

varying symptoms of different poisons are due to the fact
that toxic influences are probably confined to a single tissue ;
that woorara affects the nerves of motion alone, and that
crotaline affects only the blood. Chemistry points out the
relations of diabetes to cataract, carbuncle and gangrene,
and of albuminuria to retinitis. These are but hints of what
may be expected from perfected etiological diagnosis as ap-
plied to a multitude of surgical diseases.

Rigid clinical observation and exactness in diagnosis dis-
play their beneficial influence in the Simplification of Treat-
ment and the reluctant resort to Operation. This constitutes
the third and last characteristic of modern surgery which I
enumerated at the outset.

It is more and more apparent that the benign or malig-
nant character of new growths, and consequently the pro-
priety or impropriety of removal, is to be determined from
their clinical rather than their anatomical peculiarities. Tu-
mors, therefore, once operated on, certain glandular hypertro-
phies of the breast, for example, are often left to themselves
in the confidence that they are self-limited affections. Others
due to scrofulous or syphilitic disease are made to disappear
by medical aid alone. Electrolysis, judging from what it is
claimed to have accomplished, may prove an efficient agent
for the destruction of certain hyperplastic growths.

An exact appreciation of the bone producing power of the
periosteum has in various ways, especially in operations for
necrosis and excision, enabled results to be obtained with a
minimum of mutilation which but a few years ago were
hardly looked for. The theoretical inferences of Oilier and
the facts asserted by Sedillot, may be exaggerated, but the
practical value of their researches cannot be over-estimated.
Witness the results obtained in the reparation of ununited
fracture by the method of Dr. Bigelow, an operation owing

MODERN SURGERY. 259

its almost unfailing success to investigations characteristic
of modern surgery.

The partial abandonment of the operation of Lithotomy
affords an instance of the readiness with which surgeons
avoid the effusion of blood. Lithotrity was introduced just
as Dupuytren was adding fresh eclat to lithotomy by his
bi-lateral method, but it met with no repelling reception, and
now stands as the exponent of all that is gentle, precise
and bloodless in surgical manipulation.

The modern treatment of aneurism by compression or
forced flexion affords another illustration. No one point of
operative surgery had reached greater perfection in its details
than the ligature of arteries. No operation was thought to
better display the skill of the operator or excited to greater
expectations the critical spectators of the amphitheatre, yet
it has readily given place to a method of cure which has no
witnesses but the surgeon and his patient.

The preservation of limbs is attempted where once their
amputation was thought to be inevitable. Plus je veillis,
moins j'ampute — the older I grow, the less I amputate — said
Velpeau. Between 1847 and 1853, Hutin, Surgeon of the
Hopital des Invalides, had under his observation sixty-three
old soldiers who had recovered from gunshot fractures of the
femur, but only twenty-one who had survived amputation of
the thigh. Nowhere, however, is this preservative disposi-
tion illustrated on such a scale of success as by the records
of gunshot fractures of the femur, treated by our own sur-
geons during the late rebellion.

The treatment by compression, extension, and immobility,
the substitution of dextrine or starch for cumbersome splints,
have so revolutionized the treatment of diseased joints, that
even excision as a substitute for amputation is decreasing in
frequency of performance.

Eeduction of dislocation of the hip by ether and manipula-
34

260 MODERN SURGERY.

tion alone, instead of bleeding, tartar emetic and the pulleys,
has been revived with success, only because the principles
on which this simplified practice is founded have been made
plain and precise by modern investigation. The anatomical
points connected with this operation it is well remembered
were admirably elucidated before this Society at its Annual
Meeting in 1865.

The limited application of the trephine at the present day
in fractures of the skull, its use being almost proscribed by
French surgeons, is in great contrast to the frequent resort
to its aid which prevailed within the recollection of surgeons
still active. Fractures are treated almost without the aid
of apparatus. Chopart's and Pirogoff's amputations, Syme's
operation for stricture, the tying and cutting of varicose
veins, are less and less frequently performed. The illusions
and exaggerations of tenotomy and other subcutaneous sec-
tions, if not in club-foot and staphyloraphy, at least as ap-
plied to the cure of flexed fingers, of stammering and of dis-
torted spines, are looked upon as curiosities of the past, and
yet within the memory of most surgeons these very opera-
tions, from their ingenuity and originality, were deemed in-
dications of the advancement of surgical science.

The disposition to limit the merely mechanical part of
surgery is an increasing one. Though the art of performing
operations is not likely to cease pre-occupying the minds of
surgeons, it has evidently lost the preminence which charac-
terized it at the beginning of the present century.

To dethrone the bistoury when surgeons are daily multi-
plying, may seem like inconsistency, but the aspirants of sur-
gical science no longer find, by the exercise of inventive skill
in the multiplication of manoeuvres, the realization of their
ambition. Ingenious devices are not looked upon as neces-
sarily improvements, and still less are they deemed disco-

MODERN SURGERY. 261

veries. The scrutiny which operations undergo prior to their
performance does not spring from deference to a public
prejudice which attributes to surgeons an over-anxiety to per-
form them, nor is it due to a sentimental idea that the knife
should be the resource only when everything else has been
tried. Surgery was never bolder than it is now, but its
boldness has no affinity with constitutional coolness, or cold-
blooded audacity ; these constitute the traits of a surgeon
who makes operative surgery the chief reliance of his sys-
tem of therapeutics, and who only looks at possibility of per-
formance before undertaking his operations.

True boldness rests on accuracy of diagnosis, which,
based upon a scientific pathology, tells beforehand the or-
ganic condition of parts diseased, teaches how to favor and
facilitate the processes by which nature effects her cures ;
whether danger may be advantageously incurred, and when
neither a steady hand nor adroit manipulation can interrupt
or arrest the inevitable progress of disease.

The genuine surgeon does not operate merely because
there is nothing else to do, nor hesitate to declare the power-
lessness of his skill, rather than compromise the good repute
of his calling. In his eyes surgery is no longer a mechani-
cal art, nor the operator an artist more or less adroit. Ope-
rative dexterity is to him but a secondary acquirement, and
its possession far from marking the great difference in surgi-
cal reputations. Yelpeau shone above others not by his
talent as an operator, which was in no way remarkable, but
by the penetration of his diagnosis and the far-seeing wis-
dom of his decisions.

If at one time all advancement seemed to come from
across the Atlantic, it can no longer be said that the United
States, New England, or even Massachusetts, are not contri-
buting their full share of improvement in the comprehensive

262 MODERN SURGERY.

studies involved in the principles of surgery, and their prac-
tical application. The present high standing of the Medical
Profession in this community, largely due to the influences of
your own organization, and the yearly increasing opportu-
nities which facilitate the acquirement of a medical education,
can scarcely fail to maintain that progressive professional
advancement, some of the features of which I have attempted
imperfectly to trace.

SOME IMPROVEMENTS IN MIDWIFERY.

By G. "W". GARLAND, M.D.

OF LAWRENCE.

READ JUNE 2, 1868,

SOME IMPROVEMENTS IN MIDWIFERY.

The older members of this Society have marked with in-
terest the advancement which has been made from time to
time, during the last thirty years, in many of the departments
of our profession : — in the methods of teaching, in physiology,
pathology, and therapeutics, and in the treatment of many
diseases ; in the improvement in surgical instruments, and
operations in certain cases.

But it will be admitted, that while in these departments of
medicine much of probability and surmise, much of circum-
locution and complexity, has been removed, the study of Ob-
stetrics is still overloaded with details, and the art with des-
criptions of operations and manoeuvres some of which never
need be performed. And it may not be regarded by this
learned body as presuming, if I ask if this science cannot be
freed from certain trammels which oppose its perfection.

However carefully authors and teachers may point out
minute particulars relating to obstetrics, there are certain
demonstrations needed for which language is inadequate.
Theory leaves our ideas very imperfect — practical knowledge
cannot be acquired from books in any department of medicine,
more especially in obstetrics, where the sense of touch is so
nearly the only guide.

By attending women in labor, the physician acquires bold-
ness, quickness, and experience, which render him able to
operate skilfully in difficult cases ; and the practitioners be-
fore me will acknowledge individually that many of the

266 IMPROVEMENTS IN MIDWIFERY.

manoeuvres they adopt in the practice of obstetrics were
suggested to their own minds, not from books, but by cases
which occurred in their practice. And, gentlemen, the
modifications in the practice of obstetrics which I am about
to present to you, were first suggested to my mind by the
mother of inventions, necessity.

During the first fifteen years of my practice I followed the
books in "turning," using the right or left hand as the case
or presentation required. My left arm having become dis-
abled by rheumatism, and being called to turn in a case re-
quiring the left hand, I made an attempt to turn with the
right hand. Meeting with difficulty, it occurred to me, while
my hand was in the womb, to rotate the child on its long
axis ; accordingly I spread my hand out upon the body of
the child, and during the absence of pain I changed the po-
sition, and turned with ease.

For the last fifteen years, in many of the malpresentations
I have been called to adjust or treat, instead of adopting the
manoeuvre to the presentation, I have placed the child by
rotating in a position to improve, if need be, the presentation,
and to suit my own convenience.

In so doing, I have made, in my judgment, several improve-
ments and discoveries which may not be wholly new to you,
yet were original with myself, and some of which are not re-
ferred to in any of the works which I have read.

It is a settled principle with me, that in order to easily
effect version by the feet, in cases demanding that manoeuvre,
such as delayed malpresentations, placenta prsevia, &c, the
hand should be introduced into the womb posteriorly to the
presenting part, and passed along the posterior wall of the
uterus in search of the feet, and the child should be so placed
by rotating, that the feet, foot, or knee can be brought down
along the posterior wall of the womb, for the evident reason
that the abdominal muscles yield, and offer less, much less

IMPROVEMENTS IN MIDWIFERY. 267

obstruction, than the spine of the mother, to the version of
the child.

When the hand is passed posteriorly to the presenting
part, whether it be the head or shoulder, it is easy to see
that the part will be raised upward, and thrown forward,
enough to give place for the hand, which will relieve its con-
tact with the superior strait of the pelvis ; while if the hand
is passed anteriorly to the presenting part, this does not
readily give place for the hand, as it is opposed by the lum-
bar vertebrae.

Besides this, if the hand is introduced anteriorly to the
presenting part of the child, in bringing down the feet the
pubic arch becomes an unavoidable fulcrum, over which the
arm is compelled to act at a mechanical disadvantage, while
the perinaeum resists the end of the lever to which the power
is applied. It will be remembered, also, that when the
head of the child is posterior to the hand and arm of the
operator, in the first attempt to ascend, it is thrown forward by
the anterior curve of the lumbar vertebrae, in many instances
absolutely preventing version when the hand and arm of the
accoucheur is large, while no such inconvenience will be met
when the hand and arm are posterior.

A moment's reflection will convince any one that rotating
preparatory to turning is advisable in many cases of shoulder
presentation.

In arm and shoulder presentations the rotation should be
made backward, from right to left, or from left to right, as
the case may require. When the right arm presents, if the
child be rotated from right to left backward, the presenting
arm must of necessity return above the superior strait of the
pelvis and into the uterus. When the left hand presents,
the child should be rotated from left to right backward, when
the presenting part will also return.
35

268 IMPROVEMENTS IN MIDWIFERY.

It will be seen that my practice differs from that recom-
mended by Dr. Simpson, not only in the object of rotating,
but in the manner.

But, Fellows, great as is the advantage of rotating before
turning in many arm presentations, it is of minor importance
when compared with the superiority of this manoeuvre in all
cases where version by the vertex can be produced, and
delivery effected without turning. This, in my judgment, in-
cludes all malpresentations, such as the forehead, face, chin,
posterior parts of the head, neck, shoulders, back, belly, and
funis.

Rotation and version by the vertex are preferable to turn-
ing in all these malpresentations of the superior parts of the
child, because it is much more easily effected, with less suf-
fering to the mother, and with greater safety to both mother
and child. This is self-evident. In version by the feet, the
head and breech are compelled, per force, to pass each other
in the evolution, subjecting the womb to a distention at a
given point, sufficient to receive two of the largest transverse
diameters of the child, the head and breech ; while in rotat-
ing, the womb is but little changed in its form. When the
uterus by its contractions has clasped itself around the body
of the foetus, we should strive to make as little change as
possible in the figure and form of the child.

Version by the vertex can be accomplished after rotating
in all malpresentations, if we except some of the deviated
presentations of the pelvic extremity, as I shall soon attempt
to show.

But, first, what is the best, or most favorable position of
the child in utero, when labor commences? It is when
the vertex lies at the mouth of the uterus, with the chin rest-
ing against the sternum, the knees flexed upon the abdomen,
the tip of the shoulders on a line with the ears, with arms
resting on the chest. In this position, each contraction of

IMPROVEMENTS IN MIDWIFERY. 269

the womb tends to expel the child, as an attempt to seize the
slimy, tapering eel will illustrate. The harder the fish is
grasped, the greater will be the force with which it escapes
from the hand. In this position the child is conical, taper-
ing like a sugar loaf toward- the breech.

In all malpresentations, then, the child should be placed,
if possible, in this the most favorable position, in order to
secure safety to the child and a natural labor and delivery
to the mother.

To explain my method of effecting changes in malpresen-
tations is the object of my remarks. But for me to attempt
at this time to refer to the various malpresentations, and to
give the manoeuvre for each particular case, would extend my
paper to an inconvenient length — I propose, therefore, to
call your attention to a few presentations and their treat-
ment, and leave the principles with you to approve or con-
demn as your judgment may dictate.

Let us, then, suppose a case : the second position of the
right shoulder, with protrusion of the arm. In this position
the pelvis of the foetus will be toward the left, and in the up-
per portion of the uterus, while the head is in the right iliac
fossa. Now if the mother has a roomy pelvis, and has had
previous confinements, this presentation need not give anxiety
to the practitioner, for the reason that version by the feet
will not necessarily compromise the safety of the child.

But if it be a first confinement and the accoucheur meets
with difficulty in introducing the hand into the vagina and
womb — and if, after considering the diameter of the pelvis
carefully, he has fears that he may find it difficult to deliver
the head, rotating and version by the vertex should be at-
tempted, for the reason that, if successful, this will afford
greater security to the life of the child, and a natural labor
to the mother. If, after rotating has been effected, the head
cannot, from any cause, be rightly adjusted, the position of

270 IMPROVEMENTS IN MIDWIFERY.

the child will be so much more favorable for turning by the
feet, that the manoeuvre is most emphatically advised.

Before describing the manoeuvre, allow me to ask you to
consider, that when the hand is once in the womb, it becomes
a part and parcel of its contents, and that the hand is held
more or less firmly against the child by uterine action ; and
it is worthy of note that this uterine force is at all times just
enough to obviate any necessity of grasping any part of the
child to effect rotation. The concavity of the hand fits the
convexity of the child's body. We see, then, that if the hand,
thus placed and held, is made to traverse the internal cer-
cumference of the womb, the body of the child must follow it,
while the head of the child will be rolled or turned over by
the wrist or arm of the operator.

All the authors I have read, advise the use of the right
hand in right shoulder presentations, and the left hand in left
shoulder presentations, while I recommend the reverse when
version by the vertex is the object. In the case just supposed,
the right shoulder presents and the arm protrudes. In this
case the left hand should be introduced into the vagina in
the usual way and passed along the back of the arm to the
shoulder, and over the shoulder till the heel of the hand, so
to speak, rests upon the neck and shoulders ; the hand is then
to be spread out over the back of the child. During the
absence of pain, the child is made to rotate backward from
the right to the left of the mother and child. The right hand
can be used in this presentation, by rotating the hand in the
pelvis, after its introduction, so as to bring the palm of the
hand against the back of the child, and rotate as described
above.

Rotation having been effected, the head is to be adjusted
by bringing the hand down over the head, and seizing the
occiput in the palm, when the vertex can easily be brought
down, and the relative position of the head and shoulders,
chin and sternum accurately ascertained and secured.

IMPROVEMENTS IN MIDWIFERY. 271

The hand should then be withdrawn during or at the com-
mencement of a pain, so that the vertex may become fixed in
the superior strait of the pelvis. The case can then be left
to go on as in ordinary labor, and treated as a case of
primary vertex presentation. If from any cause the labor
fails to go forward, the forceps, ergot, &c, can be used with
more safety to the child, than what obtains in podalic version.
As you know, there are other shoulder presentations ; but
as I apply the same principle to each one of them, it is un-
necessary to detain you by referring to them.

In all cases of presentation of the face, occiput, forehead,
&c, the hand should be introduced into the womb to effect
adjustment of the head. The reason why complete introduc-
tion of the hand into the uterus is preferable to allowing
the hand to remain in the vagina and pelvis, to effect
version by the vertex, as recommended by authors, is this—
"When the hand is introduced so as to grasp the head, the po-
sition of the shoulders is ascertained, and after rotating, and
often without rotating, the head can be seized in the hand, and
placed in its natural relation to the shoulders, sternum, and
pelvic passage. But if we rotate the head with the hand in
the pelvis, we do so at the risk of producing a kink in an
already twisted neck. Besides, adjustment can be much more
speedily effected, with less suffering to the mother. All, or
most of us, have witnessed the tenesmus, and the reflex action
produced on the uterus, diaphragm and pelvic muscles by
the presence of the hand in the vagina. The pains are
greatly augmented by every motion of the hand, at a moment
when absence of the expulsive effort and uterine action are
desirable, while little effect is produced by the arm when the
hand has passed beyond the head.

Let us suppose, for the purpose of illustration, a presenta-
tion of the left side of the head, or neck, in the left occipito-
iliac position ; the occiput inclining to the left iliac fossa,

272 IMPROVEMENTS IN MIDWIFERY.

while the face inclines to the right iliac fossa. What is to
be done in such a case ?

In this presentation, as well as all others of the head, it
is important that the position of the shoulders should be
ascertained; accordingly, the left hand should be passed
along the right iliac fossa, and right side of the child's neck,
to the breast, and spread out upon the chest. During the
absence of pain, the child should be made to rotate from left
to right, forward ; at the same time pressure should be made
upward. As the child rolls over, it is easy to see that as
the face is carried over from right to left, by the wrist of the
operator, the vertex will naturally slide over the superior
strait of the pelvis. Before withdrawing the hand, the vertex
position can be fixed as already described.

Prolapsion of the umbilical cord is regarded by all authors
and practitioners as a very serious complication of labor ;
not that the life of the mother is endangered, but it is ex-
tremely destructive to the child. Dr. Churchill's tables
show that in 722 cases of prolapsion of the funis, 375 were
lost, or more than one half. Any improvement, then, in the
treatment of a prolapsed funis should, to say the least, be
well received by the profession.

I beg leave to call your attention for a few moments to
the effect that rotation of the child in utero will have on a
prolapsed funis, wherever or whatever may be its position.

The circumference of the body of a foetus at the umbilicus,
at the close of the full period of gestation, is from ten to
fifteen inches, and the length of the cord is eighteen or twenty
inches, sometimes more. If the child, then, be turned com-
pletely round on its axis, so as to occupy the same position
it did before rotation was effected, ten to fifteen inches of
the cord will be reeled on to its body, requiring that much
of the prolapsed portion, provided the cord could be wound
about the body directly transverse to its long axis ; but as

IMPROVEMENTS IN MIDWIFERY. 273

the cord must of necessity pass obliquely or diagonally,
much more of the cord will be required; and it will be found
that semi-rotation will be quite sufficient, except where the
cord is greatly elongated.

Prolapsion of the funis occurs more frequently in women
who have borne children than in primipara, the uterine walls
having, in the former, in some degree lost their tenacity.
This is favorable to rotating.

In many cases prolapsus occurs in connection with neck,
shoulder, back and abdominal presentations, the treatment
of which by rotation effectually disposes of the funis.

In prolapsion in head presentations, however, the case is
quite different, and the danger to the child much greater. It
is in cases where the prolapsed funis is the only complication,
that rotation is of such great importance and advantage.

What are the steps to be taken, then, when the vertex pre-
sents, with occiput to right, and face to the left of the ob-
lique diameter of the pelvis, with pulsating cord prolapsed
between the arms, over the left side of the neck, and back
of the left ear of the child, with its loop in the pelvis,
while the head is above the superior strait? The funis
should be brought to the left of the pubic arch, and held by
the right hand, while the left hand is introduced, and passed
up the right iliac fossa to the shoulders, and back of the
child ; then the child should be made to rotate to the right
or left as the pulsations of the cord or other indications de-
mand. The rotation should be made from the placental
end of the cord, the impulse of the foetal heart being the
guide. As the cord recedes, the fingers of the right hand
should follow it till it disappears above the head.

When we realize the facility with which this manoeuvre
causes the funis to return into the uterus, we can scarcely
restrain a smile when we picture the great Eamsbotham
dallying with a prolapsed funis on the end of a bit of

274 IMPROVEMENTS IN MIDWIFERY.

whale-bone; or Dr. Croft, with his hand in the womb, bear-
ing aloft an unwelcome funis, seeking some hook or crook
on which to hang it. The plan of Dr. Thomas, of New
York, is entitled to consideration, if it can be resorted to
before the membranes are ruptured.- I have no doubt it is
an effectual method, but not often available.

As the foetal heart may continue to act after its impulse
ceases to be felt in the cord, it should be returned at once
by rotating, unless the accoucheur is assured that the prolap-
sion has existed for a considerable time.

I will call your attention, gentlemen, to one more pre-
sentation requiring manual assistance.

A physician is called to the lying-in room, and is in-
formed that the " waters broke " several hours before his
visit. Contractions of the womb have commenced, and are
increasing. He makes a vaginal examination, and although
the os has scarcely begun to dilate, he finds a head presenta-
tion, and informs the patient and friends that " all is right "
and leaves for a few hours.

On his return he learns that the pains have increased in
vigor. Another examination is made, and the os found to
be dilated to perhaps twice the size of a crown piece, with
a puffy portion of the scalp slightly protruding at every pain.
The patient is told she is getting on finely. The physician
feels it will not be safe (fee safe) for him to leave again,
and he concludes to remain and watch the progress of the
case. Frequent examinations are made. Vigorous pains
continue, the os dilates slowly, and the head remains the
same as at the beginning in its relations to the superior
strait.

In a few hours more, the patient becomes flushed in the
face ; pulse accelerated ; great thirst is complained of; there
is unusual heat in the vagina, and the Doctor is questioned
as to the cause of this delay and suffering. Unfortunately

IMPROVEMENTS IN MIDWIFERY. 275

the medical man in attendance does not comprehend the
difficulty, and the patient is told that " nature must have
time " ; that she must make the most of her pains.

Time passes. Ergot is injudiciously given. Friends get
anxious ; the patient's strength begins to fail. The efforts
of nature are unavailing. The head at length becomes
wedged in the superior strait. The friends and attendants
are no longer to be controlled, and a consultation is de-
manded. The long forceps or craniotomy is the alterna-
tive ; either compromising the life of the patient under the
circumstances. If the mother and child are lost, the friends
console themselves that all was done that could have been
done.

Change the scene, and suppose she has attending her a
physician who perceives, at once, the cause of the delay :
who sees that nature is not able to flex the head •; that at
every pain the chin is forced from, instead of towards the
sternum; that the head thereby has become an inclined
plane, and that half the expulsive force of each pain is
thrown transversely or obliquely to the perpendicular axis
of the pelvis. What does he do ? He simply produces
flexion of the head, when the labor pains immediately be-
come effective, and the delivery of a living joy into the arms
of a fond mother is the result. Nothing is ever publicly
known of the case ; but, gentlemen, there is a silent con-
sciousness of power in the breast of that physician, worth
more than jewels.

How is flexion produced in such a case ? Authors tell us
to adjust the head with the hand in the vagina; while I
recommend that the hand be passed beyond the head, for
the reason that often one of the causes of nature's failure in
this case is a twisted neck. At the moment the waters
escape, the shoulders may not be on a line with the ears, and
the uterus, contracting upon the body and head of the child
36

276 IMPROVEMENTS IN MIDWIFERY.

while thus situated, may hold them in this unnatural relation.
To adjust the position, then, the body may need to be slight-
ly rotated, and before the hand is withdrawn flexion of the
head can be effected much more easily and quickly, and with
less suffering to the mother, than with the hand in the
vagina.

For the purpose of version by the feet, in placenta previa,
&c, authors tell us to introduce the hand into the uterus
without hesitation, but caution and recaution us not to resort
to such a formidable operation under any other circum-
stances. The reason for this, I do not understand.
* Many a practitioner will throw off his coat with a flourish,
and call with great assurance for a supply of oil when he
finds a foetal hand in the vagina, who will sleep in an ad-
joining room in perfect composure while his patient suffers,
for hours, untold agony, on account of some obliquity in the
presentation of the head, which nature is unable to correct,
because, forsooth, he has the books to pillow his head upon.
If he cannot diagnosticate the case, he can repeat " Meddle-
some midwifery" " Nature must do her own work" and other
shields to ignorance.

It is my firm conviction, Fellows, that when introduction
of the hand into the womb to ascertain the exact relations
and position of the child in difficult cases, and when rotat-
ing to effect adjustment, shall have come into favor and gen-
eral practice, podalic version will be rarely resorted to, and
the forceps will be used much less frequently than at the
present time.

I beg you will remember, gentlemen, that the remarks I
have just made were prepared to conform to the half hour
allowed me, and for the ears of practitioners, not students.
Hence the want of minor details as to the position of the
patient, the proper time for each manoeuvre, the successive
steps to be taken, &c. &c. I trust, however, I have pre-

IMPROVEMENTS IN MIDWIFERY. 277

sented the leading facts sufficiently clear to give you a guide
to their principles, and that you may have confidence to test
them in your practice, so that they may be brought out to
the public by some one, in a more elaborate form, and so
embellished as to find that favor with the profession at large
to which they are entitled.

ENUCLEATION OF THE EYEBALL.

By B. JOY JEFFRIES, M.D.

OPHTHALMIC SURGEON MASS. CHARITABLE EYE AND EAR INFIRMARY,
MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY.

READ JUNE 2, 1868,

ENUCLEATION OF THE EYEBALL.

I have found among my patients a perhaps natural horror
in reference to removal of the eyeball, no matter how use-
less this organ may have become as respects sight, and even
when it has been the seat of severe or lasting pain ; and I
have also found my medical brethren, when bringing their
patients to the specialist, shrinking from advising them to
submit to the removal of a sightless globe. There seems to
be a sort of vague sensation among the laity, and I have
found it also among physicians, that enucleation of the eye-
ball is a formidable and dangerous operation, only to be re-
sorted to in malignant disease, and as a dernier resort. The
laity also do not distinguish between the comparatively
trifling operation of enucleation of the globe, and the, at
present, rarely necessary and more formidable one of evacua-
tion of the contents of the orbit. I propose, therefore, to
fully explain the anatomy of the operation, prove its simpli-
city and show its application, and thus, I trust, place before
the members of the Society some of the advances of my
specialty, which may not have been brought to their imme-
diate notice.

The foundation of surgery rests, of course, on pure anato-
my, and the instance before us is one of the many where
anatomical points have been forgotten and only recalled
when the requirements of surgery have brought them again
into notice. The capsule of the eyeball, which now bears
the name of Tenon, was known to the students of anatomy

282 ENUCLEATION OP THE EYEBALL.

hundreds of years ago. G-alen knew it but imperfectly, for
he says (De usu part,, cap. 2), "Sexta quasdam tunica ex-
trinsecus prope accedit, in duram tunicam inserta." Eeald.
Columbus, in his " De re Anatomica " (Yenet. 1559, lib. 10),
calls it tunica innominata. The first correct anatomical
description, however, of this, to us ophthalmologists so im-
portant membrane, was given by Tenon,1 before the French
Institute in 1804, and the capsule is now known by his name.
Hyrtl7 calls it tunica vagmalis bulbi. Richet,6 aponeurosis
orbiti ocularis. Budge8 and Arnold make some further sub-
divisions of this fascia, not affecting, however, our present
operation. A most careful subdivision and description is
given by Henle.10 I would refer also to Linhart,32 Helie13
and to Richet,14 and of course to the various recent compen-
diums on ophthalmology, particularly Pilz.31 Mr. Dalrymple,2
of London, described it in 1834 as the cellular capsule of
the eye. Malgaigne has the credit of first pointing out its
surgical importance ; he considered it an aponeurosis, and
called it albuginea. In 1840 Mr. Lucas,9 of London, and
in 1841 O'Ferrall,4 in Dublin, and Bonnet,3 of Lyons, re-
described this membrane, each independently of the other,
and therefore naturally individually considered themselves the
discoverer. This was one of those circumstances still too
often occurring, where anatomical and physiological truths
are claimed as novelties, without a previous thorough search
through medical literature, which would often prevent the
critic from the disagreeable necessity of showing that there
is in reality nothing new under the sun.

I will here give, in order, a brief account from each of
these last three authorities mentioned, because their investi-
gations were made in special reference to the pathology and
treatment of affections of the eye, and lead directly to the
substitution of enucleation of the globe for extirpation of
the contents of the orbit.

ENUCLEATION OF THE EYEBALL. 283

Mr. Lucas called Tenon's capsule the submuscular fascia,
and thus explains its demonstration : — " The eye and its
appendages, with half an inch of the optic nerve, should be
removed from the orbit and placed upon a plate, the cornea
being downwards. The masses of fat, together with the
loose cellular tissue and bloodvessels, should be carefully
dissected away, and the muscles be turned forward towards
their insertions, not dissected as if with a view of exposing
their appearance, but merely expanded on the surface of the
plate. If the neurilemma of the optic nerve be now ex-
amined, it will be found covered with a fine fascia, which
can be easily raised with the forceps, and with little difficulty
can be traced off the neurilemma to the sclerotic coat at
the point where the nerve enters. It will now be found to
cover the posterior aspect of the sclerotica, and to advance
as far as the insertions of all the muscles of the eye ; at
these points it turns upon itself, lines the ocular surfaces of
the muscles, and passes backwards along them to where
they surround the optic nerve. This fascia possesses a high
degree of elasticity, and forms rather a membranous sheath
for the sclerotica than an expansion for the muscles ; it
takes the form of the eyeball, and acts the part of a mem-
branous cup for the organ to move in, separating it from the
bellies of the recti muscles, and covering the ciliary nerves
as they pass onwards to pierce the sclerotica. In the dead
eye, more or less fluid will be found to exist between this
cup-like membrane and the eyeball, which always enables
the anatomist to separate one from the other with the great-
est facility."

Dr. O'Ferrall has the merit of a pathological application
of the capsule. Mr. Haynes Walton11 gives a print of his
own dissection, and a condensed account from O'Ferrall,
who says, " It is a distinct tunic of a yellowish white color
and fibrous consistence, continuous in front with the posterior

284 ENUCLEATION OF THE EYEBALL.

margin of the tarsal cartilages, and extending backwards
to the bottom or apex of the orbit, where its consistence
becomes less marked; the sharp end of a probe or a
director will be sufficient to separate it from the eyeball, by
breaking the fine cellular tissue which connects them.
Within, where the eye glides over it, the surface is smooth,
the external or orbital part loose and cellular. The muscu-
lar portions of the recti muscles lie outside of this tunic,
which isolates and protects the eye in the most perfect
manner possible. Half an inch posterior to its anterior
margin are six well defined openings, through which the
tendons of the muscles pass to their insertions in the sclero-
tic coat, and over which they play as through a pulley."

Bonnet, in his treatise on "Section of tendon and mus-
cles," says, " When I meet with a case favorable to the ap-
plication I would thus proceed to enucleate the globe. Dis-
tending the lids with suitable instruments which I employ, I
would cut the internal rectus with the same precautions as
for the operation for strabismus. Then sliding the scissors
along the wound I have made, between the sclerotic on one
side and the subconjunctival fascia and muscles on the
other, I would cut in turn all the recti muscles near their
ocular insertion. We need then only divide the obliqui as
near as possible to the globe, and afterwards the optic
nerve. The globe will then be removed without my inter-
fering with any vessel or nerve, and without penetrating the
orbital fat." By not touching vessel or nerve, of course he
means as in the old operation for extirpation of the contents
of the orbit.

Stober,6 of Strasbourg, first performed this operation in
1841.

Here I think it worth while to go back to Tenon's descrip-
tion, which, as it has been so often misquoted, I translate
from his own words : —

ENUCLEATION OP THE EYEBALL. 285

" A little behind the tendon of each of the recti muscles
around the eye, there is formed a tendinous fascia, which
proceeds from the fleshy fibres of each of the recti muscles and
the membranous sheath surrounding and penetrating them.
These tendinous fasciae separate from the tendinous muscles
which they arise from ; they are a continuation of the fleshy
fibres of the muscles, and spring from the membranous
sheath enveloping each of the muscles. The largest and
thickest belongs to the abductor muscle. It springs from the
external side of the muscle, and is attached to the external
angle of the orbit near the lower edge of the lachrymal gland.
It acts as a counter brace on the muscle, and prevents it
while contracting from pressing on the eye. The fascia of
the adductor (rectus internus) is shorter and not so thick as
that of the abductor (rectus externus). It commences at
the point of termination of the fleshy fibres, and is implant-
ed on the inner angle of the orbit at the edge of the nasal
canal. It acts also as a counter brace. The tendinous
fascia of the elevator of the eye (rectus superior) forms an
aponeurotic band extending from one side of the orbit to
the other, to the depth of the upper lid. The tendinous
fascia of the depressor (rectus inferior) is lost in the lower
lid." Tenon called it, <•' the new tunic of the eye."

For the surgical purposes of our operation we may regard
it as a membranous sac on which the globe rolls, and which
is pierced by the tendons of the muscles, the cutting of which
tendons in front of the capsule at their insertion into the
globe will leave this membranous sac as a basis or support for
an artificial eye, and the muscles being still attached to this
capsule will therefore move it and the glass eye lying on it
in nearly as great degree as when an artificial eye lies
against a stump of the globe left by disease or surgical
interference.

This so simple operation, recommended by Bonnet, is in

286 ENUCLEATION OP THE EYEBALL.

such contrast to the former one, really to be dreaded, of ex-
tirpating the whole contents of the orbit, muscles, nerves,
fasciae, gland, &c, that it is a wonder that ophthalmic sur-
geons did not sooner practise it, but not more wonderful
than that even to this day, perhaps, unfortunate patients
are undergoing extirpation of their orbital contents, much
as certain bivalves are their contents, and with not very dis-
similar instruments.

1 would dwell upon this, because one of the purposes of
this paper, as I have said, is to prove to you how simple and
little to be dreaded this present operation is, and that it has
no relation with extirpation of the orbital contents, an
operation only applicable to certain tumors in the orbit.
The method of operating for enucleation of the globe,
taught me by Prof. Arlt, in Vienna, is the following : —

Dilating the lids with a speculum and holding in one hand
a pair of toothed forceps and in the other a small pair of
curved scissors, the tendinous insertion of the rectus inter-
ims muscle on the globe is seized and cut through. Retain-
ing the grasp with the forceps the conjunctiva is cut around
the cornea, and the tendons of the other three recti divided at
their insertion. The scissors are now passed in behind and
the optic nerve severed close to the globe, which will then
start forward, and we have only to cut the tendons of the
two obliqui muscles to free the eye from the orbit and leave
intact the capsule of Tenon with the muscles attached to it.35
This operation I have done, and it is comparatively easy,
when inflammation has not bound down the conjunctiva or
fastened the globe to the capsule, but under anaesthetics, at
least, I would advise the following: — Raise with forceps a
piece of conjunctiva near the corneal edge, pass in the
curved scissors and separate the conjunctiva all round the
cornea. With strabismus hook lift up and cut all four recti
tendons as carefully as in operating for squint. Steady the

ENUCLEATION OF THE EYEBALL. 287

globe with fingers and thumb, and pass a large pair of curved
scissors behind it and divide the optic nerve, which releases
the globe from the orbit, and then we can sever the obliqui
attachments. There will be but little bleeding. A piece of
ice in the orbit is all that is required, and filling the latter
with sponge or charpie and applying pressure is not only
absolutely useless, but apt to be painful. A glass eye may
be inserted, often within a week, and always should be as
soon as possible to avoid shrinking of the soft parts, which
it certainly does.

Perhaps some one will here say to me, there must be
something wrong about all this, for I certainly was taught
and learned, that removal of the eye was a severe and dan-
gerous operation. Moreover, I remember the first proceed-
ing was to enlarge the palpebral aperture in order to have
room to work in. My reply is, I desire only to remove the
useless and now offending organ, namely, the eyeball, and
would as soon think of slitting up the lids, as a dentist
would of enlarging a man's mouth to extract a molar tooth.

Yet the following is from the American Edition of Erich-
sen's Surgery, 1866. "Extirpation of the eyeball is also
occasionally called for, when in consequence of injury
or disease one eye has become disorganized and the vision
of the other is sympathetically affected, and can only
be preserved by the removal of the globe that is already
useless. The operation may be performed in the following
way : — The surgeon standing in front of the patient, makes
an incision through the outer commissure of the lids as far as
the edge of the orbit. The eyelids are then well everted
and held apart with a wire speculum. The surgeon next
passes a double hook into the globe and draws it well for-
ward ; then with a curved, broad pair of scissors he divides
the conjunctiva at its upper part, and then proceeds to cut
38

288 * ENUCLEATION OF THE EYEBALL.

across the several muscles of the orbit, and lastly the optic
nerve."

The operation of enucleation has been found so simple,
so effective when needed, and so perfectly adapted to its
ends, that we may well wonder at its having been neglected
so many years after Bonnet proposed and Stoeber performed
it. What was called sinking the eye, namely, cutting out a
piece and letting the contents of the globe escape, was for-
merly the operation practised where now enucleation is in
place. Pathology and experience soon taught that in the
operation of sinking the eye, exactly that portion of the
globe was left which was most often the source of trouble,
namely, some part of the ciliary region. Hence soon came
from one and another the improved method of removing the
anterior part of the globe up to the edge of the retina or
or a serrata, leaving the rest to form a stump. Dr. E. Wil-
liams, of Cincinnati, especially, proposed at the Ophthalmic
Congress, at Paris, 1862,15 to remove a portion of the an-
terior part of the eye instead of enucleation, for the purpose
of having a better stump for the eye to move on. He cut
through the ciliary body, the only part of his operation I
would object to, as we must remove all of the ciliary region
to avoid sympathetic trouble of the other eye, as time has
since proved. This operation, when done with stitches
passed behind the portion to be removed, now has Mr.
Critchett's name attached to it, as he introduced it for sta-
phylomata.16 Four or five curved needles are passed through
the globe just behind the part to be. cut off, and the wound
brought together, an operation which might be in place in
certain cases, rather than enucleation, and we must then
decide between the two. The disadvantages are the long
time consumed in recovery, the probable subsequent pain,
great swelling during suppuration, and the possibility that
even then enucleation of the stump must be practised, as I

ENUCLEATION OP THE EYEBALL. 289

have been obliged to do where I have found traumatic or
artificial sinking has occurred. On the other hand, we may
get good union of the sclerotic and no great pain or swell-
ing. But the stump remains a doubtful source of irritation.

Prof. Knapp,36 of Heidelburg, has quite recently proposed
a modification of this operation which may prove of very
great service. He passes the needles through the conjunc-
tiva alone, above and below, and by drawing it together
closes the sclerotic wound, thus avoiding any chance of sym-
pathetic irritation of the other eye, which the continued
presence of stitches in the sclerotic may produce.

I will at once answer the question which may arise, by
saying the false eye will move nearly if not quite as well
and sometimes even better, bedded on Tenon's capsule, than
if resting on a stump which it may possibly irritate. I may
say, I have seen the muscles move the capsule sufficiently to
deceive at first glance, even an oculist, as to whether the eye
was false or not. But the point is just here, and it must be
kept steadily in mind. The capsule will move the artificial
eye well enough, and the stump, if composed of any part of
the cornea or ciliary region, is never safe from the danger
of producing sympathetic irritation.

In the adult, when the features, the bones and soft parts
have reached their fullest development, an objection to enu-
cleation does not apply to the same extent as in the young.
The objection is this, and I would dwell upon it because
little if anything will be found in regard to it in the ophthal-
mic literature which you will meet. After enucleation of
the globe by the method proposed by Bonnet, the orbital fat
seems to become absorbed, allowing the muscles and Tenon's
capsule to sink in more than natural, and more than when a
stump or portion of the globe remains. When clone in youth
before the bones are perfectly formed, or perhaps even after-
wards, the osseous tissue about the orbit seems also to

290 ENUCLEATION OP THE EYEBALL.

shrink, giving a different outline and feature to this compared
with the other side of the face. The expression is peculiar,
making the patient on that side look as if thinner or not in
good health, to which the bright cheek and lips give the denial.
This I have seen so marked, that it always arises to my
mind in deciding whether to enucleate the globe or abscise
the anterior portion of it, and I have in the young chosen
the latter simply on these cosmetic grounds, otherwise enu-
cleation is greatly to be preferred, removing as it does all
source of irritation which has called for the operation.

That the laity may better understand the necessity, sim-
plicity and effectiveness of enucleation, by being taught
through you to no longer dread it as something terrible, to
be avoided till the last, is, as I have said, the purpose of this
paper. It remains, therefore, to show when and why we
ophthalmologists employ it.

Enucleation may be needed simply to get rid of an en-
larged or staphylomatous globe which the lid will not cover,
or which we desire to remove to give place to a false eye ;
or, as a prophylactic operation, to subdue or prevent sympa-
thetic inflammation in the other eye. Years ago (1802)
Beer, and afterwards especially Himly in 1843, noticed and
laid stress upon the fact, that continued irritation or chronic
inflammation of one eye caused its fellow to sympathize.
Grsefe,18 Arlt,19 Bader,20 Muller,21 and Augustine Prichard22
of Bristol, have since then given us their special studies of
sympathetic irido-choroiditis, so that at present it is as re-
cognized as dreaded by the ophthalmologist. Trouble in
the sound eye does not commence, as you might suppose, in
the retina or nerve or choroid, but in the uveal tract, and
gradually extends back from there towards the posterior
part of the globe. A patient with an injured or inflamed
eye will have, in the other sound one, intolerance of light,
sensation of fulness, even perhaps perceptible to the touch,

ENUCLEATION OF THE EYEBALL. 291

inability to use the eye, fatigue of accommodation and con-
traction of the range of accommodation, long before he may
apply to the surgeon, who at once recognizes this insidious
sympathetic irritation from the other eye.. I do not propose
here, however, to discuss sympathetic inflammation, except
so far as regards the removal of the injured or inflamed
eye, to control or avoid it.

It is rather curious that the idea of destroying an injured
or inflamed eye to prevent its acting on the other, comes
from veterinary surgery. This in the horse was at first
done by pushing a nail into the globe or putting lime be-
tween the lids ; afterwards by Wardrop, in a less cruel man-
ner, by opening the globe. Credit is due the English for first
having proposed destruction of one eye to save the other
from sympathetic trouble, and formerly the same method was
used as in the horse by Barton,23 Crompton and others.
Grasfe destroyed the eye by passing a thread through the
sclerotic and cornea, or through the ciliary body. Walton
and Taylor, as Dr. E. Williams, of Cincinnati, above quoted,
preferred to cut away more of the cornea, to remove if
necessary an old cataract, results of exudations, foreign
bodies, &c. Now it is curious to see, that notwithstanding
the knowledge which then existed of Tenon's capsule, its
being repeatedly brought into notice, and even enucleation
within this membrane having been distinctly proposed and
to a small extent practised, yet ophthalmic surgeons did not
commence the employment of this method of removing an
injured or inflamed eye to save its fellow, till Mr. Critchett25
in 1851, probably from seeing how successful enucleation
was when practised for tumors, staphylomata, &c, and how
well the false eye set and moved in the cup of the capsule,
proposed and carried out this operation in preference to
others for sympathetic irritation, and, as Prof. Grasfe said in
1857, its practicability and success were at once established.

292 ENUCLEATION OP THE EYEBALL.

Again, in I860, he says, practitioners ought to understand
enucleation better than they do, for they seem to have a sort
of dread of it, as if dangerous to the other eye, and as
though it was a severe and bloody operation. The success
attending Mr. Critchett's operation of course led other En-
glish ophthalmic surgeons to follow him, and enucleation
soon became so frequent in London practice as to astonish
the French and German schools, and naturally excite their
opposition, which was perhaps fortunate, as the whole sub-
ject of enucleation for sympathetic trouble has in conse-
quence been now thoroughly discussed, and the results care-
fully weighed and considered, so that we already have some
definite laws to guide our decision.

The more this operation has been used by surgeons at the
great centres of ophthalmic practice and clinical study and
teaching, the more strongly do they speak of its value, sim-
plicity and necessity. A few quotations from the highest
authorities in the English, French and German ophthalmic
schools will here be directly in place, and probably have their
due weight.

Dr. Bader,26 of London, says, " The facility with which
enucleation is performed, its great freedom from risk, and
the adaptability of an artificial eye, ought to make us con-
sider a disorganized eye, which is the seat of pain or annoy-
ance, as a foreign body whose removal the sooner it is ac-
complished the better. If not painful at the time it is a de-
formity, and is liable at any time of ill health to become the
seat of inflammation, and affect sympathetically the opposite
organ. It is not only unwise, but incorrect to bring before
the patient's imagination the idea of < taking the eye out, '
and omitting the scientific advantage of excising; medical
men must soon learn to value the operation."

Mr. Jonathan Hutchinson27 says, in regard to enucleation
of the eyeball even during the acute stage of traumatic pan-

ENUCLEATION OF THE EYEBALL. 293

ophthalmitis, " Whenever I am satisfied that an injured globe
is utterly lost, I always advise its excision without loss of
time. By adopting this course the patient's suffering, often
extreme, is at once put an end to, and I think, also, the risk
of sympathetic inflammation of the other eye is avoided. I
have excised globes in all stages of inflammation, and have
never seen the slightest ill consequence, whilst the patients
have invariably been most grateful for the complete relief
afforded."

Mr. Critchett, at the Ophthalmic Congress at Heidelburg,
in 1863, says: — 1st. That injuries which cause sympathetic
ophthalmia are those which occur in the ciliary region. 2d.
The effects of such inflammations differ in important points
from those dependent on the other forms of iritis. 3d. Lo-
cal or constitutional remedies have as little beneficial effect
on the eye as surgical interference. 4th. Operation must
be suspended till all inflammation is gone by, and even then
a doubtful prognosis must be given. 5th. In view, therefore,
of the uncontrollable inflammation and the danger of total
blindness, it may be perhaps safer, when injuries have affect-
ed the ciliary region and threaten long irritation, to enucleate
the injured eye before signs of trouble appear in the other."

From the Franco-German school Wecker28 says, " It is
vain to attempt to substitute iridectomy or section of the
optic nerve for enucleation. There is no longer any doubt
of the necessity of removing an eye which is lost, as soon as
it becomes dangerous to the other. The only question aris-
ing is in reference to the case itself and the time when re-
course must be had to enucleation. We are forced to enu-
cleate: 1st. Whenever one eye remaining sound, the other is
the seat of intolerable pain which, not yielding to remedies,
makes us fear for the sound one. 2d. In every case where
a lost eye has given rise to sympathetic irido-choroiditis in
the other, no matter how slight, for this is our only means

294 ENUCLEATION OF THE EYEBALL.

of controlling it. 3d. In every case where the eye, till now
sound, has become in any degree amblyopic, its range of
accommodation rapidly diminished, intolerant of light, or
incapable of prolonged use; these symptoms often being
the precursors of irido-choroiditis. Enucleation will be all
the more urgent when careful examination cannot find for
these troubles, either in the eye itself or in the general con-
dition, other cause than this sympathetic influence in question.
Under all circumstances when in doubt, it is better to ope-
rate too early than too late, for we may find enucleation
useless after sympathetic irido-choroiditis is fully estab-
lished."

From the various ophthalmic clinics of Germany we also
have concurrent testimony. Grsefe's18 and Arlt's19 results
and observations I have already quoted. Pagenstecher, at
Wiesbaden, found enucleation necessary from the following
causes : —

1st. Traumatic irido-choroiditis occasioned by

(a) Lesion of the iris, resulting from its being nipped

between the edges of the wound.

(b) Lesion of the choroid.

vitreous.

(d) Presence of a foreign body in the eye.

(e) Lesion of the capsule of the lens.

(f ) Choroiditis after reclination, or depression of

the lens.
2d. Incipient exudative irido-choroiditis and haemorrhage

from the choroid.
3d. Processes leading to staphyloma (choroiditis serosa).
4th. Extensive separation of the retina.
5th. Tumor developing from the choroid or sclerotic.
6th. Formation of bone within the choroid.
Let me here add one more testimony from Dr. Mooren's30

ENUCLEATION OP THE EYEBALL. 295

clinical experience for eleven years with 32,000 patients in
Diisseldorf. He says, " The causes of sympathetic disease,
according to my observation, may be divided into three
distinct groups. 1st. Direct injuries of the ciliary region.
2d. Mechanical irritation of the ciliary body, whether by
the action of a foreign body (wearing an artificial eye), or
by the lens turned into a foreign body by displacement, re-
clination, luxation, staphyloma, etc. 3d. Every inflammation
of any part of the uveal tract, when by cyclitis it has
reached its culminating point." And finally, as do all other
authorities, Dr. Mooren gives, "pain upon pressure in the
ciliary region as the never-failing symptom which pointed
to and proved danger from sympathetic disease. When this
is present, the only possibility of saving the second is by
enucleation of the first affected eye."

To the above I would add the testimony of my own ex-
perience in ten years of ophthalmic practice in this commu-
nity. In the medical literature of this country you will find
reports of successful cases of this operation, coming from
the scientific ophthalmologists of our larger cities, who strive
to avail themselves of the sound sense of the English, the
elan of the French, or the patient industry and scientific
attainments of the German surgeons in this specialty.

I trust, therefore, my efforts have succeeded in proving to
you that enucleation of the eyeball from within the capsule
of Tenon, is un anatomical possibility, a surgical necessity
and a powerful prophylactic remedy.

Note. This paper having been intended for a large State Medical Society,
will explain to my brother ophthalmic surgeons why no comparison is made
with simple iridectomy, section of the optic nerve, or of the ciliary nerves.

The accompanying wood cuts are from photographs of a
diagram and dissection exhibited to the Society when the
paper was read.

Fig. 1. The lids are slit up vertically, and the four flaps turned
back. The conjunctiva dissected off and strings passed under the
tendinous insertion into the sclerotic of the external, internal and infe-
rior recti muscles, just as they would be lifted on the hook to be cut in
operating for squint. A needle is passed under the tendon of the supe-
rior rectus, which is seen to pass to the capsule of Tenon, showing itself
between the upper half of the globe and the upper lid, from both of
which it is freed. In a single wood cut it is of course difficult to give
a more definite view of a minute dissection.

Fig. 2. Represents in diagram a vertical section through the orbit
and eyeball. The heavy dotted line shows the fibrous lining of the
orbit, which at the anterior upper and lower edge passes off to the lids,
and also backwards to the globe which it surrounds to the optic nerve,
thus forming Tenon's capsule. A layer behind runs over the nerve to
form its sheath, and in front a prolongation extends forward to the
conjunctiva. The superior and inferior recti muscles are represented,
and where their tendons pierce Tenon's capsule to become attached to
the globe. It will thus be seen that cutting the tendons of the muscles
at their insertions, and the optic nerve, releases the globe and leaves
Tenon's capsule like a cup for an artificial eye to rest on and be moved
bv the muscles.

Fig. 1.

Fig. 2.

BIBLIOGRAPHIC REFERENCES.

Tenon. Memoires et Observations sur 1' Anatomic, la Pathologie
et la Chirurgie, et principalement sur l'Organe de l'CEil. p. 193.
Paris, 1816. , 1

JDalrymple. Anatomy of the Human Eye. London, 1834. 2

Bonnet. Read at Paris Academy of Sciences, Feb. 1, 1841.
Gazette Med. de Paris, Feb. 13, 1841. Dublin Med. Press,
March 3, 1841, p. 133. Annales d'Oculistique, t. v. p. 27, and
t. vii. 1842, pp. 141,237. 3

O'Ferrall. Dub. Med. Press, March 10, 1841, p. 158. Dub. Jour.
Med. Sci. Vol. 19, p. 336. 4

Stober. Annales d'Oculistique. Tome vii. p. 31. 5

Picket. Traite pratique d'Anatomie Medico-chirurgicale. Paris,

1857. 6

Hyrtl. Handbuch der topagraphischen Anatomie. Wien, 1853. 7

Budge. Ztschr. fur rat. Med. 3 R. vii. p. 273. 8

Lucas. Practical Treatise on the Cure of Strabismus. London,

1840. American Journal Medical Sciences, Oct. 1841. 9

Henle. Handbuch der Anatomie des Meschen. Vol. 2, Prt. 3. 10

Walton. Treatise on Operative Ophthalmic Surgery. London,
1853. 11

Bonnet. Traite des Sections Tendineuses et Musculaires. 1841. 12

Helie. Theses de Paris. 1841. 13

Picket. Anat. Chirurg. Paris. 1860. 2d edit. p. 324. 14

E. Williams. Congres Internationale d'Ophthalmologie. Paris,

1862, p. 139. 15

Critchett. Royal London Ophthalmic Hosp. Reports. Vol. 5.
Parti. 1863. 16

Pagenstecher. Klinische Beobachtungen aus der Augen heilanstalt
zu Wiesbaden. 1862. p. 42 et sequitur. - 17

Grafe. Archiv f. Ophth. B. 3. Abth. 2. B. 12. Abth. 2. B. 6.
Abth. 1. 18

Arlt. Zeitschrift der Gesellschaft der Aertze zu Wien. 1859.
Nr. 10. 19

Bader. Prager Med. Vierteljahrsschrift. 57. Band. 20

Mutter. Archiv. f. o. B. 4. Abth. 1. 21

Prichard. " Association Journal." Oct. 6, 1854. 22

Barton § Crompton. London Medical Gazette, 1837. 23

300 BIBLIOGRAPHIC REFERENCES.

Walton <5f Taylor. Annales d'Oculistique. t. 34, p. 256. 24
Critchett. Allgemeine Wiener Zeitung. Feb. 14, 1860. Lancet,

1851, p. 368. 25

Bader. .Royal Lond. Opth. Hosp. Reports. No. 1, 1857. 26

J. Hutchinson. Roy. Lond. Opth. Hosp. Reports. Vol. 5, Part 4. 27

Wecker. Traite theorique et pratique des Maladies des Yeux. 28

Blodig. Zeitschirft der Gesellschaft der Aertzte zu Wien. 1860. 29

Mooren. Opthalmiatrische Beobachtungen. Berlin. 1867. 30

Pilz. Compendium der Operativen Augenheilkunde. Prag. 1860,

p. 3. 31

Linhart. Wiirzburger Verhandlungen. Bd. 9. Heft. 2 et 3, 1859. 32

Lenoir. These sur la Strabisme. 33

Demarquay. Traite des Tumeurs de l'Orbite. Paris, 1860. 34

Liebreich. Eine Modification der Schiel Operation. Archiv f. Opth.

12. 2. 35

Knapp. Staphylomabtragung und Vereinigung der Wunde durch

Bindehautn'ahte. Archiv. fur Opth. 14. 1. 36

Hart. London Lancet, Jan. 1863. 37

Carter. Br. Med. Jour., Nov. 1864. 38

Wecker. Gazette des Hospitaux, 93. 1864. 39

Hulke. British Med. Journal, Jan., 1866. 40

Lawson. London Lancet, Jan., 1863. 41

Lawson. London Lancet, Aug., 1864. 42

Wolf. Gazette des Hospitaux, 100. 1864. 43

Calderini. Jahrbb. 135. p. 356. 44

EXTRA DIGITS

By BURT G. WILDER, M.D.

READ JUNE 2, 1868.

EXTRA DIGITS

A child conies into the world with two thumbs instead of
one, or with an extra little finger, or, it may be, with an
additional great or little toe.

The parents, if ignorant and superstitious, are dismayed;
like the ancient physician, "whose pathology was mythology,"
they bewail the deformity as an omen of evil, past, present
or future, rather than as detrimental to the elegance or
usefulness of the afflicted member.

But if they are intelligent and disposed to take the matter
calmly, they console themselves by recalling instances of
cats and dogs, and even of innocent lambs, which had more
than the usual number of digits, yet whose dispositions and
those of their parents and offspring gave no sign of demo-
niacal influence. Some of their friends, too, have seen or
heard of other children with the like peculiarity, whose
parents, nevertheless, were Christians, who themselves came
to no bad end, and whose descendants, even if they inherited
the deformity, were in no way remarkable, or, at any rate,
not objectionably so.

And so when the physician comes again, and is consulted
in the matter, they are quite prepared to receive his more
accurate information upon other cases, and to follow his
advice with their own. If he be only a practising physician,
with no other object in life than to get his patients into good
condition as soon as possible, he either advises to leave the

306 EXTRA DIGITS.

extra digit alone, since it is not greatly in the way and may
even be useful, or, if this is not the case, proceeds to remove
it after the approved methods : meanwhile recounting to his
hearers the like cases which have come within his knowledge ;
some who had seven, eight, nine and even ten fingers or toes ;
others, six fingers on each hand and six toes on each foot;
while in other cases, these lesser peculiarities of the limbs
had been associated with such extraordinary malformations
of the body and head, that the astonished parents now con-
gratulate themselves that it was no worse, *and that their
child was not born a Cyclops or a Hydrocephalus, instead of
a simple " Sexdigitist."

But if, on the other hand, our physician is one who while
exerting his utmost skill for his patient, yet allows his mind
to pass from visible effects toward invisible causes, from
isolated facts toward general principles, then will he take
careful note of this case, will make perhaps a sketch and a
dissection of the specimen, and then, as opportunity occurs,
will ponder the whole subject and seek to solve the many
questions which now crowd upon his mind.

What are the causes of such malformations, and how are
they produced? in which of the two sexes are they more
commonly found ? on hands or on feet ? on the right or the
left side ? on the ulnar or the radial, the tibial or the fibular
border ? and what is the occasion of the difference if any
exists ? All these, and many others which readily suggest
themselves, now impart to such anomalies a far deeper
interest than before, and if he looks upon succeeding cases
with something more than a practical eye as to whether
the digit shall be removed or not, and if he now makes
inquiries which seem to have no reference to the physical
well-being of the child or the mental anxiety of the p'arents,
it is not, as some would have it, because science has dulled
his heart to sympathy; his former feelings were merely

EXTRA DIGITS. 307

human; they have not now degenerated into what is less,
but have rather been elevated to what is more than human.

But here, let me insist that our hypothetical Doctor, and
every one who takes up this subject, shall get together as
large a number of cases, and as full a history of each, as is
possible, before attempting to draw from them any general
conclusions. For in these days when the scientific world is
flooded with theories as to the nature, the causes and the
significance of the variation of organized beings ; when yet the
normal standards have not been determined ; when there is
with some a willingness to ascribe such variations to mere
chance, and with others a disposition to attribute them to phy-
sical laws and condition, acting as if of themselves and inde-
pendently of a Supreme Intelligence ; when it is so easy to
speculate, and so tedious to investigate ; now, of all times, is
it necessary that we restrain ourselves, and utter no theory
which has not the best foundation in facts, which it is in our
power to gain.

Variation is boundless and infinite. Probably no two
individual things or beings are exactly alike. The cells of
the bee and the webs of the geometrical spider, which have
so long been held up to us as examples of mathematical
exactness, are now found to differ widely among themselves.
No two crystals are identical ; nay, even no two symmetrical
halves of crystal are identical ; more marked, though too
often overlooked, are the differences between the two halves
of the bodies of animals and of men; males and females
correspond, but are not the same ; parent and child are alike,
yet diverse ; even species are by some supposed to vary and
to change so as to lose their identity.

Merely expressing in passing my total disbelief in the
truth of this last supposition, let me call attention to the
individual variations of the Fingers and the Toes, a group of

308 EXTRA DIGITS.

cases which appeal to the medical man from nearly every
stand-point of our most comprehensive profession.

For the surgeon they are a not infrequent occasion for
operation. For the anatomist, their own structure and their
connections with adjacent parts afford material for dissection ;
and the physiologist is interested in their various degrees of
mobility and usefulness. The embryologist is still in doubt
as to the manner of their formation and especially the means
of their occasional reproduction; and the teratologist may
record and consider their not infrequent association with other
and more serious deformities. To the psychologist, the degree
of influence which the mother's mental condition may exert
upon the production of these and other physical peculiarities
should be a subject of serious consideration, before the ancient
and still popular opinion upon this matter is set aside as
groundless. The statistician may find ample employment
for his industry in recording the prevalence of extra digits
in certain localities, among certain peoples, and more
strikingly in certain families, where they disappear and again
appear after several generations in a most remarkable man-
ner. And finally, to each and every one of the above men-
tioned classes of medical men, these extra digits are too
often a source of regret and disappointment ; since it is rarely
the case that the specimen is preserved or drawings made,
or the history recorded to such an extent as to fully answer
the inquiries of any two of them.

All the cases of polyclactylism, a synopsis of which I shall
now present, are from the human species : for though cats
and dogs and other animals and birds are known to possess
extra digits, their number is too small and the individual
histories too incomplete for our present purpose ; in addition
to which, hardly any two of the common species possess the
same normal number of digits.

I have also confined myself on this occasion to what is

EXTRA DIGITS. 309

called sexdigitism ; the presence of a single supernumerary
finger or toe ; partly on account of the greater number of
such cases and the greater ease of recording and tabulating
them, but chiefly because there are high authorities who
look upon every extra digit as a rudiment of a second indi-
vidual ; so that it is better to confine my statements to these
cases, which, whatever may prove to be the correct view as
to the higher numbers, are, in my own opinion, simply the
result of the undue subdivision of, or an after-growth from,
the primitive limb, and not in any way the indication of a
double monster.*

From various sources, specimens, casts, figures, descrip-
tions, letters, and word of mouth,f I have brought together
the principal facts which could be obtained concerning one
hundred and fifty-two individuals who have or have had six
fingers or toes upon one or more of their extremities. The
number may seem large, and it is really more than three
times as great as any one has had before : but I wish before
proceeding farther to express my regret that it is not one
thousand, rather than one hundred and fifty -two ; but as these
are all which are now accessible to me, I am induced to offer
them at this time, with three principal objects in view : —

1st. That I may impress upon others the value of each and
every fact relating to these cases, since most of them bear
directly upon questions now under discussion.

* How do the advocates of the view referred to, account for the presence of
extra digits upon more than one of the limbs ? do they represent portions of as
many imperfect monsters ? or of one and the same monster, accurately, and as
a general thing, evenly, distributed upon the perfect individual ? Neither hy-
pothesis is very reasonable.

t Lest others may take the pains to record the same cases again, the writer
has recorded all the cases published by Otto, Monstrorum Sexcentorum Descriptio
Anatomica, 1841 ; b3r Simpson, in his Obstetrical Memoirs and Contributions, ii. p.
346 ; by T. Annandale, of Edinburgh, in the Prize Essay upon Malformations,
Diseases and Injuries of the Fingers and Toes, 1866 ; by Arthur Mitchell, in a paper
upon Blood Relation in Marriage, Mem. Anthropological Society of London, ii.
402 ; by Dr. Foltz, Homologie des Membres Pelviens et Thoracique ; Journal de

310

EXTRA DIGITS.

2d. To suggest a general method of recording such cases.

3d. To indicate, so far as these cases go, the direction
which we may expect will be taken by the final results of a
much larger number.

The following table indicates the principal results of this
record and tabulation of cases :

SEXES.

No
Individ-
uals.

.of

Affected
Limbs.

Region.
Ant.Post. ?

Side.
R. L.

Borders.
U. R. ? T. Fib. ?

Males

168

109

Females

Doubtful

195

20
142

17
135

3
12

24
110

4
45

2
40

6
21

152

289

Ant. Anterior extremity.

Post. Posterior "

R. Eisflit.

L. Left.

U. Ulnar border.

It. Radial "

T. Tibial "

F. Fibular "

No one, so far as I know, has hitherto offered any facts or
expressed any opinion as to the comparative frequency of
extra digits in the two sexes ; and in some cases the sex of

Physiologie, vol. vi. p. 49, 1863 ; by Reaumur, L'Art de Faire Eclose Oiseaux
Doraest., 1751, p. 377, quoted incorrectly by Huxley, on the Origin of Species, p.
93 ; by Darwin, on Animals and Plants in Domestication, 1868, vol. ii. ; by Dr. John
Struthers, Variation in the number of Fingers and Toes and of the Phalanges,
Edinburgh New Phil. Journal, July, 1863 ; by Dr. J. B. S. Jackson, Catalogue
of Museum of Boston Society for Medical Improvement ; by Vrolik, Cyclopedia
of Anatomy and Physiology, iv.-ii. p. 948. He has also had access to all the
specimens in the Warren Anatomical Museum of the Harvard Medical College,
in Prof. Wyman's Museum in Cambridge, and in the Museum of the Boston
Society for Medical Improvement ; and has likewise found a large number of
isolated cases in books, and by inquiring has procured reliable accounts of cases
now living. Several important and interesting cases which were sent by Dr.
George J. Fisher, of Sing-Sing, New York, the only one who has devoted him-
self especially to these malformations, and who has published a valuable treatise
upon Diplo-teratology (concerning Double Monsters), were unfortunately
received too late for tabulation ; but these and all others which can be obtained
the writer hopes, at some future time, to publish both singly and by tabulated
results ; the present contribution being intended only as an incentive and help
to others. Probably there is scarcely a neighborhood where one or more cases
may not be discovered.

EXTRA DIGITS. 311

the patient is not even mentioned, although it must have been
known to the recorder.

It is a generally received opinion that not only is the
male the more highly organized, but that he is also more
liable to malformations resulting from an excess of develop-
ment, such as double monsters, &c, while the female is
thought to be more commonly subject to arrests of develop-
ment. Now whether extra digits are always so many
primary subdivisions of the rudimentary hand or foot, or
whether they are subsequent outgrowths from the hand or foot
already formed, they are in both cases the result of an excessive
action in one form or another, and so it is interesting to find
that of one hundred and fifty-two individuals affected with
extra digits, eighty-six are males and only thirty-nine females :
the sex of the remaining twenty-seven is not known.

The one hundred and fifty-two individuals represent six
hundred and eight limbs, of which two hundred and eighty-
nine or nearly one half were affected. Of these two hundred
and eighty-nine affected limbs, one hundred and forty-two
were on the right side and one hundred and thirty-five on
the left side. The difference between the two sides is there-
fore very slight ; it does not even appear that the two hands
differ any more than the two feet, and while the preponder-
ance of cases is upon that which is generally regarded as
the dynamic side of the body, perhaps it was not to be ex-
pected that parts which vary so slightly in their normal
structure and uses should present any striking differences
in their malformations.

We come now to a most important and interesting division
of the subject: namely, as to the relative frequency of a
sixth digit upon the anterior and posterior extremities, the
hands and the feet.

Here I must admit having been very decidedly predisposed
towards the result which has been reached, for it was this very
question which led me first to take up the subject.
41

312 EXTRA DIGITS.

While studying the various comparisons of the fore and
hind limbs of man and animals which have been instituted
by different anatomists, it appeared to me that far too much
weight had always been attached to the structure and atti-
tude of the fore limbs, on account of their greater functional
importance ; so that they were generally unable to see how
nearly the two limbs may be made to correspond in a
symmetrical or antagonistic manner, as do those of the right
and left sides.

The greater functional value of the hand was not to be
questioned ; but it occurred to me that if it could be shown
that the hand and the whole arm are more variable than
the foot, in attitude, in proportion of parts and in the number
of digits, then their morphological value would be diminished
to a corresponding degree ; and anatomists would be more
ready to accept the posterior limbs as the surer guides in
their comparison of the two. Now it is known to all that
the more various and complicated motions are executed by
the hands ; also that among the different species of animals,
the anterior limbs undergo the greater modification of struc-
ture and position to suit the wants of the monkey, the bear,
the bird and the fish; also that when, as in the cat,
the number of digits is not the same upon the two limbs,
the greater number is generally on the hand.

These considerations, anatomical, physiological and zoolo-
gical, as to the variability and consequent less morphological
value of the hand, are now strikingly confirmed by the
statistics of sexdigitism. For of the two hundred and eighty-
nine affected limbs, one hundred and ninety-five, or more
than two thirds, are hands, the remainder being feet.

Here there is a possible disturbing element; for it may
be said that the extra digit would be more often removed from
the feet than from the hand ; indeed the additional thumb is
sometimes thought by the possessor to be a decided advan-

EXTRA DIGITS. 313

tage, either in grasping a pen-handle or in taking anything
from his vest pocket, by opposing the tips of the two
thumbs.*

But I hardly think the consideration above mentioned
will account for the great difference which exists between the
hands and the feet in this respect. The result confirms the
opinion already expressed by Struthers, which, however, was
based upon a much smaller number; while it is directly
opposed to the opinion of Darwin, who in his last work, on
Animals and Plants under Domestication, says that he has
tabulated forty-six cases and finds a slight preponderance in
favor of the feet, there being seventy-five feet and only
seventy-three hands ; but this probably includes all varieties
of polydactylism.

No less striking than the above is the comparative fre-
quency of the extra digit on the ulnar and radial borders of
the hands, the tibial and fibular borders of the feet ; and as
this, too, bears directly upon a part of the question as to
the comparison of the fore and hind limbs, I will dwell
upon it for a moment.

A distinguished French anatomist,f who has declared his
belief in the existence of a true symmetrical or polar relation
of the fore and hind limbs, has coupled with it a theory as
to the binary composition of the thumb and great toe ; the
desire for this arises from his feeling that both these digits
are too large for a correspondence with the little toe and
little finger, opposite which they come when the hand and foot
are symmetrically placed j but his only facts in its support

* There are also one or two families in Germany whose members pride them-
selves upon the possession of an extra thumb, and there is an Arab Chieftain
whose ancestors have from time immemorial been distinguished by the double
thumb upon the right hand. But in view of the great difficulty of eradicating
the malformation from a family, one is reminded in all these cases of the fable
of the fox who had lost his tail, and ever afterward recommended others to get
rid of theirs.

f Dr. Foltz.

314 EXTRA DIGITS.

are a few cases of extra or double thumbs and great toes, which
he thus conceives to represent the normal condition of the
parts. But the facts we have to offer indicate that the little
finger and little toe are by far the more often double or
supernumerary : for of the one hundred and ninety-five hands,
one hundred and ten had a supernumerary little finger, and
only forty-five an additional thumb ; while upon the feet there
are twenty-seven extra little toes and only twenty-one great
toes.

The greater difference in the relative frequency of an extra
digit on the ulnar and radial side of the hand, as compared
with that between the tibial and fibular borders of the feet,
we may associate with the greater functional distinction
between the thumb and the little finger : but the greater
variability of the little toe and little finger does not appear
to be in accordance with the idea already alluded to, that
variation is more frequent in that sex, and in that region of
the body, where the greater development and activity exists.

There is one matter which does not come strictly under
the head of extra digits ; but as it is a variation of a similar
nature, and especially as the cases are both rare and ex-
tremely valuable, I will say a few words concerning it.
There are a few instances (of which one specimen is in the
museum of the Boston Society for Medical Improvement)
of a thumb possessing an additional phalanx so as to be long
and finger-like, yet opposable to the other digits. The chief
value of such cases consists in this : that the most serious
objection to symmetry, in the minds of those who still in-
sist upon a comparison of the fore and hind limbs as parallel
parts, and who consequently consider the thumb and great
toe to correspond with each other, is the fact that both these
digits normally consist of only two phalanges, while all the
others possess three. It is my own opinion that this diffi-
culty is a wholly superficial one, and that the difference in

EXTRA DIGITS. 315

the number of phalanges is simply a difference of quantity
like that in the number of digits themselves, and therefore
no basis for a morphological comparison ;* but every such
case of a thumb or a great toe having three phalanges is so
much toward the means of convincing anatomists that they
really correspond, not to each other, but to the little toe and
little finger, respectively.

It may be interesting to know which are the more common
extra digits among these cases. Of one hundred and eighty-
five limbs, being all of which both the sex, side of body, limb,
and border are known, the following is the order of frequency.
There is a slight difference between the two sexes, but the
numbers are too small to prove anything of single digits, and
I give only the totals. The order of frequency is as follows :
Right little fingers, .... 53
Left little fingers, . . . .52
Right little toes, . . . . 18
Right thumbs, . . . . .17
Left thumbs, . . . . . 17

Left little toes, 11

Left great toes, . . . . 10
Right great toes, .... 7

~185
So far we have treated of extra digits according to the
separate limbs upon which they occur, and, excepting when the
sexes were mentioned, have dealt with the individual sex-
digitists only in quarters, giving to each limb a distinct place
in our results as well as upon the blanks. Let us now put
together the limbs of each individual, and see how they were
combined. To do this we must first make a division of the
sexdigitists into those which had but one limb affected, those
which had two, those which had three, and those which had
four ; these four groups being called Unisexdigitists, Bisex-

* Morphological Value and Relations of the Hand ; Silliman's Am. Journ. of
Science and Art, xliv. July, 1867.

316

EXTRA DIGITS.

digitists, Trisexdigitists, and Quadrisexdigitists. But a sec-
ond subdivision, the use of which will presently be seen, may
be into Unisexdigitists and Polysexdigitists : of the former
there are seventy- three, and of the latter seventy-five ; these
being divided as follows among the three minor groups —
Bisexdigitists thirty-four, Trisexdigitists eleven, Quadrisex-
digitists thirty.

Combination of Extra Digits in Individuals.

Unisexdigitists .
Right thumbs
Left

? "

Left little finger
Right " "

Right little toe

Left " "
? <« c«

Left great "
Right " "

p it tt

No. of
Individ.

16
11
14

Recapitulation,
m Unisexdigitists,

S ('Bisexdigitists
1 s Trisexdigitists

CO I

•3 L Quadrisexdigitists

Total

34
11
30

148

Bisexdigitists.
Both little fingers

" " toes

" great "

" thumbs

" " or little fingers

" great or little toes
Right little finger and little toe

" " " great or little toe

Trisexdigitists.
Both little fingers and right great toe

" « « u a litUe „

" thumbs and left great toe

" great toes and left thumb

" " " " right "

" " " " " little finger

Quadrisexdigitists.
Both little fingers and both little toes

tt a a tt a g-vglt "

tt it tt n n p a

Both thumbs and both great toes
" fingers or thumbs and both great or little toes

No. of
Individ.

24
2
2
1
2
1
1
1

6
1

EXTRA DIGITS. 317

As will be seen from the foregoing table, the preponder-
ance of hands among the unisexdigitists is very great, being
sixty-two to eleven ; an exaggeration of the ratio which we
found by using all the separate limbs : but in our former
results the little fingers have been far more numerous than
the thumbs, whereas taking the unisexdigitists alone, we have
forty-one thumbs to twenty-one little fingers ; from which it
appears that if a person has but a single extra digit it is more
than five times as likely to be on a hand as on a foot ; and if
on a hand, twice as likely to be a thumb as a little finger.

But how is it now with the multiple group ? In fifty-four
of the individuals the hands were affected, and in thirty-two
the feet; the trisexdigitists and quadrisexdigitists of course
having one or both of the hands or of the feet affected. But
what is most remarkable is the complete reversion of the
ratio of thumbs and little fingers from what it was with
the unisexdigitists ; for here there are forty-seven individuals
in whom one or both the little fingers was double, while in
only five were there extra thumbs ; so that if a man has two
or three or four extra digits, he is nine times as likely to
have a little finger as a thumb. The number of posterior
digits is too small for this calculation, but it is evident that
little toes are more common than great toes.

There is another point brought out by this table; namely,
that when there are two extra digits the repetition is far
more likely to be lateral than longitudinal; that is, corres-
ponding digits are doubled on opposite sides of the body rather
than on opposite ends: two little fingers, or two thumbs,
rather than a little finger or thumb and a great or little toe.
Indeed there are but two cases of this latter kind ; one being
that of a right little finger and a right little toe, the other
being of a right little finger and either a great or little toe.
There are not yet enough cases to afford any evidence in
either direction upon the question whether the great toe o<r
the little toe corresponds to the thumb.

318 EXTEA DIGITS.

The number of trisexdigitists is too small for this separate
calculation ; but the more common combination is of the two
little fingers and the right great toe. The quadrisexdigitists
also are too few to afford any reliable result; but here as
usual the little fingers predominate ; in six cases they coexist
with both little toes, and in only one case with the great
toes ; while in six cases they coexist with toes of which it is
not known whether they are great or little.

There are many other facts concerning extra digits which
must be passed over here with a brief mention. Nearly all of
them possessed well-formed nails. A few were pedicellated
and not at all under the control of the will : but more often
the attachment was firm and the only motion was between
their own phalanges which generally agreed in number with
those of the adjoining digit. Sometimes there was a sixth
metacarpal or metacarpal bone, and there were all possible
degrees of completeness from this to a single phalanx attached
to the base of the terminal phalanx of the adjoining digit.
Some of the extra digits were amputated in infancy, and they
seldom re-appeared, though in one case it grew for a second
and a third time. This reproduction of digits, however, is
more common after amputation in utero, when they are some-
times even developed upon the extremity of an arm severed
above the wrist.

A large number of cases have been observed in some
parts of Scotland where intermarriage is common; but
although some infirmities se'em to be the direct result of
this custom, it may be that extra digits are not caused
thereby, but only spread abroad. In one case the defor-
mity is connected with the fact of the mother having
worked next to a girl with double thumbs, before her
marriage.

As may be expected, the previous extent of extra digits in
the family constitutes by far the most general predisposing

EXTRA DIGITS. 319

causes ; but there must have been some, or at least one, first
and antogenous case. The oldest on record is that of a son
of Goliath of Gath, who had six fingers on each hand and
six toes on each foot ; but it is hardly probable that all sex-
digitists are descendants of the Philistine.

The whole great subject of hereditary transmission must
be passed over with a few words : in all cases I have
recorded what was known of the ancestors, the brothers and
sisters and the descendants j with cross references when any
of these constituted others of my cases.

Dr. Struthers, who has published by far the completest
account of original cases of sexdigitism, thinks it necessary
to make a primary subdivision of them into the hereditary
and the non-hereditary cases ; but the second class will also
embrace all those of which nothing is known as to ancestry ;
and moreover, though it is certain that there is a very decided
tendency to the perpetuation of the parents' peculiarity in the
offspring, sometimes even, as in one remarkable family,
gathering force as it descends through successive generations,
there being one hand affected in the first generation, two hands
in the second, two hands and a foot in the third, and all four
limbs in the fourth, yet there are so many cases in which this
seems to fail, or in which the malformation appears only after
one or more generations or not in the direct line of succession,
that I have thought best not to attempt any generalization, and
have contented myself with recording the facts so far as they
could be ascertained, mentioning not only those relatives who
did, but also the number of those who did not present this
malformation.

Of the total one hundred and fifty-two individuals, thirteen,
or one in eleven or twelve, had some other deformity beside
the extra digit : two were giants ; Anna Boleyn had a super-
numerary mamma and an additional upper tooth. Hydroce-
phalus, or some deformity of the head, existed in four cases j
42

320 EXTRA DIGITS.

harelip and cleft-palate in five ; one individual was a part of
or double monster ; varus of one or both feet was present in
four cases ; and in four there was an abnormal condition of
the organs of generation.

In addition to the points already mentioned, it is necessary
to state the date of record, to affix the name or initials, real
or fictitious, of the individual, and his residence or the
museum containing the specimen or the title of the works
where it is figured or described; all this to avoid the
possibility of using the same case a second time.

For convenience of recording these facts I have used a half
sheet blank, on which are figures corresponding to a list of
questions, the answers to which are to be given ; additional re-
marks, and a tracing or drawing of the specimen may be put
upon the back. The middle of the front is occupied by a
diagram of the palms and soles of the four limbs, upon which
it is easy to add the extra digits, so as to show at a glance
what the individual possessed.

"It is truly remarkable," writes the gifted German
anatomist, Oken, "what it costs to solve any one problem
in philosophical anatomy; without knowing the what, the
how, and the why, one may stand, not for hours or days, but
for weeks, before a fish's skull."

To know the what, the why and the how, is the aim of
every seeker after truth, and that truth is only to be reached
after long and patient work. The great deficiency in the
matter we have considered, is the lack of material ; and yet
there is enough to be had ; for in a single small town of
New England there are three distinct families in which one
or more members are sexdigitate. If I have succeeded in
showiug that extra digits may be viewed as something more
than curiosities, or as so many pathological specimens, let
me hope that no case will hereafter be allowed to go
unrecorded in its most minute particular, whether of structure
or function, or of history.

EXTRA DIGITS. 321

For if we believe that nothing happens by chance, and
that male and female, right and left, anterior and posterior,
internal and external, are not mere artificial distinctions of
the regions of our bodies, but are truly and fully the out-
ward embodiments of ideas and principles which have a
physical, a spiritual, nay a Divine origin and significance,
then the greater frequency of these anomalies in one of the
two sexes, upon one or the other side of the body, upon the
hand or the foot, will be a never-failing subject for thought
and a stimulus to further investigation.

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RECOVERY

FEOM THE

PASSAGE OF AN IRON BAR THROUGH

THE HEAD.

By JOHN M. HARLOW, M.D.

OF WOBURN.

(With a Plate.)

READ JUNE 3, 1!

RECOVERY AFTER SEVERE INJURY TO
THE HEAD.

Mr. President and Fellows of the

Massachusetts Medical Society:

I have the pleasure of being able to present to you, to-day,
the history and sequel of a case of severe injury of the
head, followed by recovery, which, so far as I know, remains
without a parallel in the annals of surgery. The case oc-
curred nearly twenty years ago, in an obscure country town
(Cavendish, Yt.), was attended and reported by an obscure
country physician, and was received by the Metropolitan
Doctors with several grains of caution, insomuch that many
utterly refused to believe that the man had risen, until they
had thrust their fingers into the hole in his head, and even
then they required of the Country Doctor attested statements,
from clergymen and lawyers, before they could or would
believe — many eminent surgeons regarding such an occur-
rence as a physiological impossibility ; the appearances pre-
sented by the subject being variously explained away.

It is due to science, that a case so grave, and succeeded by
such remarkable results, should not be lost sight of ; that its
subsequent history, termination, and pathological evidences,
in detail, should have a permanent record. My desire to lay
before the profession the sequel of this case, has not permit-
ted me to remain altogether oblivious as to the whereabouts
of my patient, and after tracing him in his wanderings over

330 RECOVERY AFTER

the greater part of this continent, I am able to present to
you indubitable evidence that my report of the case, in the
Boston Medical and Surgical Journal, was no fiction. You
will find the report in Vol. 39, No. 20, page 389, of the
Journal ; also a subsequent report, with comments, by Prof.
Henry J. Bigelow, in the American Journal of the Medical
Sciences for July, 1850.*

The accident occurred in Cavendish, Yt., on the line of
the Rutland & Burlington Railroad, at that time being built,
on the 13th of September, 1848, and was occasioned by
the premature explosion of a blast, when this iron, known
to blasters as a tamping iron, and which I now show you,
was shot through the face and head.

The subject of it was Phin. P. Gage, a perfectly healthy,
strong and active young man, twenty-five years of age, nervo-
bilious temperament, five feet six inches in height, average
weight one hundred and fifty pounds, possessing an iron will
as well as an iron frame ; muscular system unusually well
developed — having had scarcely a day's illness from his child-
hood to the date of this injury. Gage was foreman of a
gang of men employed in excavating rock, for the road way.
The circumstances were briefly as follows : —

He was engaged in charging a hole drilled in the rock,
for the purpose of blasting, sitting at the time upon a shelf
of rock above the hole. His men were engaged in the pit,

* Soon after the publication of this case in the Boston Medical and Surgical
Journal, in November, 1848, 1 received a letter from Henry J. Bigelow, Professor
of Surgery in the Medical Department of Harvard University, requesting me to
send Gage to Boston, generously proposing to defray his expenses and compen-
sate him for loss of time. Gage being quite well, and the hole in the top of his
head entirely closed, accepted this proposition, and remained in Boston, under
the observation of Prof. Bigelow, eight or nine weeks, where he was examined
by many medical men, Prof. Bigelow being thoroughly convinced, at a time
when the accident had very few believers either in the medical profession or out
of it, that the lesion was as represented — that the iron had traversed the cranium
and brain as stated. With my concurrence he reported the case, with illus-
trations, in the American Journal of the Medical Sciences for July, 1850.

SEVERE INJURY TO THE HEAD. 331

a few feet behind him, loading rock upon a platform car,
with a derrick. The powder and fuse had been adjusted in
the hole, and he was in the act of "tamping it in," as it is
called, previous to pouring in the sand. While doing this,
his attention was attracted by his men in the pit behind him.
Averting his head and looking over his right shoulder, at the
same instant dropping the iron upon the charge, it struck
fire upon the rock, and the explosion followed, which pro-
jected the iron obliquely upwards, in a line of its axis, pass-
ing completely through his head, and high into the air, fall-
ing to the ground several rods behind him, where it was
afterwards picked up by his men, smeared with blood and
brain. The missile entered by its pointed end, the left side
of the face, immediately anterior to the angle of the lower
jaw, and passing obliquely upwards, and obliquely back-
wards, emerged in the median line, at the back part of the
frontal bone, near the coronal suture. The wound thus oc-
casioned will be demonstrated and fully described to you
hereafter. The iron which thus traversed the head, is
known with blasters as a "tamping iron," is round and
rendered comparatively smooth by use, and is three feet
seven inches in length, one and one-fourth inches in its
largest diameter, and weighs thirteen and one-fourth pounds.
The end which entered first is pointed, the taper being
about twelve inches long, and the diameter of the point
one-fourth of an inch.

The patient was thrown upon his back by the explosion,
and gave a few convulsive motions of the extremities, but
spoke in a few minutes. His men (with whom he was a
great favorite) took him in their arms and carried him to
the road, only a few rods distant, and put him into an ox
cart, in which he rode, supported in a sitting posture, fully
three-quarters of a mile to his hotel. He got out of the cart
himself, with a little assistance from his men, and an hour

332 RECOVERY AFTER

afterwards (with what I could aid him by taking hold of his
left arm) walked up a long flight of stairs, and got upon
the bed in the room where he was dressed. He seemed per-
fectly conscious, but was becoming exhausted from the haemor-
rhage, which, by this time, was quite profuse, the blood
pouring from the lacerated sinus in the top of his head, and
also finding its way into the stomach, which ejected it as
often as every fifteen or twenty minutes. He bore his suf-
ferings with firmness, and directed my attention to the hole
in his cheek, saying, " the iron entered there and passed
through my head." Pulse at this time 60, soft and regular.
He recognized me at once, and said " he hoped he was not
much hurt." His person, and the bed on which he lay, was
one gore of blood. ' Assisted by my friend Dr. Williams,
who was first called to the patient in my absence, we pro-
ceeded to examine and dress his wounds. From the ap-
pearance of the wound in the top of the head, the fragments
of bone being lifted up, the brain protruding from the open-
ing and hanging in shreds upon the hair, it was evident that
the opening in the skull was occasioned by some force acting
from below, upward, having very much the shape of an in-
verted funnel, the edges of the scalp everted and the frontal
bone extensively fractured, leaving an irregular oblong open-
ing in the skull of two by three and one-half inches. The
globe of the left eye was protruded from its orbit by one-
half its diameter, and the left side of the face was more
prominent than the right side. The pulsations of the brain
were distinctly seen and felt.

The scalp was shaven, the coagula removed, with three small
triangular pieces of the frontal bone, and in searching to
ascertain if there were foreign bodies in the brain, I passed the
index finger of the right hand into the opening its entire length,
in the direction of the wound in the cheek, which received the
left index finger in like manner, the introduction of the finger

•

SEVERE INJURY TO THE HEAD. 333

into the brain being scarcely felt. Aside from the triangular
pieces already alluded to as removed, there were two other
pieces detached from the frontal bone, the anterior being
two and one-half by two inches, and the posterior one and
one-half by two inches in size, leaving the antero-posterior
diameter of the opening in the skull fully three and one-half
inches.

This examination, and the appearance of the iron which
was found some rods distant smeared with blood and brain,
together with the testimony of the workmen and of the pa-
tient himself, who was sufficiently conscious to say that the
iron " struck his head and passed through," was considered
at the time as sufficiently conclusive, not only of the nature
of the accident, but the manner in which it occurred. The
small pieces of bone having been taken away, a portion of
the brain, an ounce or more, which protruded, was removed,
the larger pieces of bone replaced, the edges of the soft
parts- approximated as nearly as possible, and over all a wet
compress, night cap and roller. The face, hands and arms
were deeply burned. The wound in the cheek was left
open, the hands and arms were dressed, and the patient was
left with the head elevated, and the attendants directed to
keep him in that position. This was at 7| o'clock, P.M.
At 10, P.M., same evening, the dressings are saturated with
blood, but the haemorrhage is abating. Has vomited twice
only, since being dressed. Mind clear. Says he " does not
care to see his friends, as he shall be at work in a few days."
Gives the names and residence of his relatives in Lebanon,
N. H. Pulse 65. Constant agitation of his legs, being
alternately retracted and extended like the shafts of a
fulling mill.

At 7, A.M., the 14th, has slept some during the night ;
appears to be in pain ; speaks with difficulty j tumefaction
of face considerable, and increasing. Recognizes his mother

334 RECOVERY AFTER

and uncle. Bleeding into mouth continues. Asks who is
foreman in his pit. Has not vomited since midnight.

On the following day, the 15th, the haemorrhage entirely
ceased. Slept well half of the night, and could see objects
indistinctly with the left eye.

For a detailed and daily record of the progress of the
case, I will refer you to the Boston Medical and Surgical
Journal of Dec. 13, 1848. It is sufficient for my present
purpose to call your attention to a brief abstract of some
of the most important features of the case which followed.

On the 15th Sept., two days after the accident, the patient
lost control of his mind, and became decidedly delirious,
with occasional lucid intervals. On that day a metallic
probe was passed into the opening in the top of the head,
and down until it reached the base of the skull, without re-
sistance or pain, the brain not being sensitive.

16th, there began an abundant foetid, sanious discharge
from the head with particles of brain intermingled, finding
its way out from the opening in the top of the head, and also
from the one in the base of the skull into the mouth.
On the 18th, he slept well nearly all night, but was as inco-
herent as ever in the morning. 22d, at 8, A.M., I learn that
he has had a very restless night. Throws his hands and feet
about, tries to get out of bed. Head very hot. Says " he
shall not live long so." 23d, I find he has rested and been
quiet most of the night. Appears stronger and more ra-
tional. Pulse, which has varied from 60 to 84 since the
injury, I find at 80. The scalp was reshaven and the edges
of the wound brought into apposition as nearly as possible,
the edges having sloughed away. The discharge less in
quantity and less foetid.

At this date, ten days after the injury, vision of the left
eye, though quite indistinct before, was totally lost. Up to
this time it had not occurred to me that it was possible for

SEVERE INJURY TO THE HEAD. 335

Gage to recover. The head had been dressed by myself
three times every day ; ice water kept on the head and face ;
the discharges carefully cleaned off, externally, while the at-
tendants washed the mouth and fauces as often as necessary,
with water and disinfecting solutions. The opening in the
top of the head was always carefully covered with oiled silk
underneath the wet compresses. To-day he appears stronger
and more rational than before ; calls for food.

Sept. 24th, 9, A.M. I find in my notes, taken at the time,
that he has a pulse at 84 ; vision with right eye, and hearing
with both ears, normal 5 bowels confined ; can tell the day
of the week and time of day ; remembers persons who have
visited him and incidents which have transpired since his
injury. This improvement, however, was of short duration,
though the discharge from the wounds had abated. I learned
that in the night following he became stupid, did not speak
unless aroused, and then only with difficulty; the integu-
ments between the lower edge of the fracture in frontal bone
and left nasal protuberance, swollen, hot and red, something
like an erysipelatous blush. Pulse 96, soft. Failing strength.
Is supported with food and stimulants. During the three
succeeding days the coma deepened ; the globe of the left
eye became more protuberant, with fungus pushing out rapidly
from the internal canthus. This fungus first made its ap-
pearance on the 19th, six days after the injury; also large
fungi pushing up rapidly from the wounded brain, and com-
ing out at the opening in the top of the head. On the 27th,
the swelling upon the forehead fluctuated. The exhalations
from the mouth and head horribly foetid. Pulse 84. Coma-
tose, but will answer in monosyllables when aroused. Will
not take nourishment unless strongly urged. Calls for no-
thing;. Surface and extremities incline to be cool. Discharge

O CD

from the wound scanty, its exit being interfered with by the
fungi. The friends and attendants are in hourly expectancy
44

336 EECOVERY AFTER

of his death, and have his coffin and clothes in readiness to
remove his remains immediately to his native place in New
Hampshire. One of the attendants implored me not to do
anything more for him, as it would only prolong his suffer-
ings— that if I would only keep away and let him alone, he
would die. She said he appeared like "water on the brain."
I said it is not water, but matter that is killing the man — so
with a pair of 'curved scissors I cut off the fungi which were
sprouting out from the top of the brain and filling the open-
ing, and made free application of caustic to them. With a
scalpel I laid open the integuments, between the opening
and the roots of the nose, and immediately there were dis-
charged eight ounces of ill-conditioned pus, with blood, and
excessively foetid. Tumefaction of left side of face increased.
Globe of left eye very prominent.

From this date, Sept. 28th, to Oct. 6th, the discharge from
the openings was very .profuse and foetid. Erysipelatous
blush on skin of left side of face and head. Pulse ranging
from 80 to 96. Speaks only when spoken to. Swallows
well, and takes considerable nourishment, with brandy and
milk ; says he has no pain.

Oct. 6th — twenty-three days after the injur}' — I find en-
tered in my note book as follows : — General appearance
somewhat improved; pulse 90, and regular; more wakeful;
swelling of left side of face abating; erysipelas gone; open-
ings discharging laudable pus profusely ; calls for his pants,
and desires to be helped out of bed, though when lying upon
his back cannot raise his head from the pillow. By turning
to one side he succeeded in rising, and sat upon the edge of
the bed about four minutes. Says he feels comfortable.
Appears demented, or in a state of mental hebetude.

Oct. 11th — twenty-eighth day.— Yery clear in his mind;
states how long he has been upon his bed, how he was in-
jured, the particulars of the explosion, and the time in the
day when it occurred.

SEVERE INJURY TO THE HEAD. 337

Oct. 15th — thirty-second day. — Progressing favorably.
Fungi disappearing ; discharging laudable pus from openings.
Takes more food, sleeps well, and says he shall soon go
home. Remembers passing and past events correctly, as
well before as since the injury. Intellectual manifestations
feeble, being exceedingly capricious and childish, but with a
will as indomitable as ever ; is particularly obstinate ; will
not yield to restraint when it conflicts with his desires.

Oct. 20th — thirty-seventh day. — Improving; gets out of
and into bed with but little assistance ; eats and sleeps well.
Sensorial powers improving, and mind somewhat clearer, but
very childish. The fungi have disappeared. The opening
in the top of the head is closing up rapidly, with a firm
membranous tissue.

Nov. 8th — fifty-sixth day. — Improving in every respect.
Sits up most of the time during the day. Appetite good,
though he is not allowed a full diet. Pulse 65. Sleeps
well, and says he has not any pain in his head. He walks
down stairs, about the house and into the piazza, and I am
informed that he has been in the street to-day. I leave him
to-day, with strict injunctions to avoid excitement and ex-
posure.

Nov. 15th — sixty -fourth day. — Returned last evening, and
learn that Gage has been in the street every day during my
absence, excepting Sunday. Is impatient of restraint, and
could not be controlled by his friends. Making arrange-
ments to go home. Yesterday he walked half a mile, pur-
chased some articles at the store, inquired the price, and
paid the money with his habitual accuracy ; did not appear
to be particular as to price, provided he had money to meet
it. The atmosphere was cold and damp, the ground wet,
and he went without an overcoat, and with thin boots ; got
wet feet and a chill. I find him in bed, depressed and very
irritable j hot and dry skin j thirst ; tongue coated ; pulse

338 RECOVERY AFTER

110: lancinating pain in left side of head and face; rigors,
and bowels constipated. Ordered cold to the head and face,
and a cathartic, to be taken and repeated if it does not ope-
rate in six hours.

Nov. 16th, A.M. — No better. Cathartic has operated

freely. Pulse 120; has passed a sleepless night; skin hot

and dry ; pain and thirst unabated. Was bled from the arm

§ xvi., and got: R. Hydrarg. chloridi, gr. x. ; ipecac, gr.

ij: M.

8, P.M., same day. — Pulse falling; heat and pain mode-
rated. Took a solution of ant. pot. tart, during night, and
slept well.

17th, A.M. — Much improved. Has been purged freely
during night, and says he feels better every way. Has no
pain in head.

18th. — Is walking about house again, free from pain in
head, and appears to be in a way of recovering, if he can
be controlled. Has recently had several pieces of bone
pass into the fauces, which he expelled from the mouth. The
discharge from the head very slight, and the opening steadily
closing up.

On the 25th he was taken, in a close carriage, a distance
of thirty miles, to Lebanon, N. H.. his home, where I saw
him the succeeding week, and found liim going on well. He
continued to improve steadily, until on Jan. 1, 1849, the open-
ing in the top of his head was entirely closed, and the brain
shut out from view, though every pulsation could be distinct-
ly seen and felt. Gage passed the succeeding winter months
in his own house and vicinity, improving in flesh and strength,
and in the following April returned to Cavendish, bringing
his " iron " with him.

He visited me at that time, and presented something like
the following appearances. General appearance good;
stands quite erect, with his head inclined slightly towards

SEVERE INJURY TO THE HEAD. 339

the right side ; his gait in walking is steady ; his movements
rapid, and easily executed. The left side of the face is
wider than the right side, the left malar bone being more
prominent than its fellow. There is a linear cicatrix near
the angle of the lower jaw, an inch in length. Ptosis of
the left eyelid ; the globe considerably more prominent than
its fellow, but not as large as when I last saw him. Can
adcluct and depress the globe, but cannot move it in other
directions ; vision lost. A linear cicatrix, length two and
one-half inches, from the nasal protuberance to the anterior
edge of the raised fragment of the frontal bone, is quite un-
sightly. Upon the top of the head, and covered with hair,
is a large unequal depression and elevation— a quadrangular
fragment of bone, which was entirely detached from the
frontal and extending low down upon the forehead, being
still raised and quite prominent. Behind this is a deep de-
pression, two inches by one and one-half inches wide, be-
neath which the pulsations of the brain can be perceived.
Partial paralysis of left side of face. His physical
health is good, and I am inclined to say that he has re-
covered. Has no pain in head, but says it has a queer feel-
ing which he is not able to describe. Applied for his situa-
tion as foreman, but is undecided whether to work or travel.
His contractors, who regarded him as the most efficient
and capable foreman in their employ previous to his injury,
considered the change in his mind so marked that they could
not give him his place again. The equilibrium or balance,
so to speak, between his intellectual faculties and animal
propensities, seems to have been destroyed. He is fitful,
irreverent, indulging at times in the grossest profanity (which
was not previously his custom), manifesting but little defer-
ence for his fellows, impatient of restraint or advice when
it conflicts with his desires, at times pertinaciously obstinate,
yet capricious and vacillating, devising many plans of future

340 RECOVERY AFTER

operation, which are no sooner arranged than they are aban-
doned in turn for others appearing more feasible. A child
in his intellectual capacity and manifestations, he has the
animal passions of a strong man. Previous to his injury,
though untrained in the schools, he possessed a well-balanced
mind, and was looked upon by those who knew him as a
shrewd, smart business man, very energetic and persistent in
executing all- his plans of operation. In this regard his
mind was radically changed, so decidedly that his friends
and acquaintances said he was " no longer Gage."

His mother, a most excellent lady, now seventy years of
age, informs me that Phineas was accustomed to entertain
his little nephews and nieces with the most fabulous recitals
of his wonderful feats and hair-breadth escapes, without any
foundation except in his fancy. He conceived a great fond-
ness for pets and souvenirs, especially for children, horses
and clogs — only exceeded by his attachment for his tamping
iron, which was his constant companion during the remainder
of his life. He took to travelling, and visited Boston, most
of the larger New England towns, and New York, remain-
ing awhile in the latter place at Barnum's, with his iron. In
1851 he engaged with Mr. Jonathan Currier, of Hanover,
New Hampshire, to work in his livery stable. He remained
there, without any interruption from ill health, for nearly or
quite a year and a half.

In August, 1852, nearly four years after his injury, he
turned his back upon New England, never to return. He
engaged with a man who was going to Chili, in South Ameri-
ca, to establish a line of coaches at Valparaiso. He re-
mained in Chili until July, 1860, nearly eight years, in the
vicinity of Valparaiso and Santiago, occupied in caring for
horses, and often driving a coach heavily laden and drawn
by six horses. In 1859 and '60 his health began to fail,
and in the beginning of the latter year he had a long illness,

SEVERE INJURY TO THE HEAD. 341

the precise nature of which, I have never been able to learn.
Not recovering fully, he decided to try a change of climate,
and in June, 1860, left Valparaiso for San Francisco, where
his mother and sister resided. The former writes that " he
arrived in San Francisco on or about July 1st, in a feeble
condition, having failed very much since he Jeft New Hamp-
shire. He suffered much from seasickness on his passage
out from Boston to Chili. Had many ill turns while in Val-
paraiso, especially during the last year, and suffered much
from hardship, and exposure."

After leaving South America, I lost all trace of him, and
had well nigh abandoned all expectation of ever hearing
from him again. As good fortune would have it, however,
in July, 1866, 1 was able to learn the address of his mother,
and very soon commenced a correspondence with her and
her excellent son-in-law, D. D. Shattuck, Esq., a leading
merchant in San Francisco. From them I learned that Gage
was dead — that after he arrived in San Francisco his health
improved, and being anxious to work, he engaged with a
farmer at Santa Clara, but did not remain there long. In
February, 1861, while sitting at dinner, he fell in a fit, and
soon after had two or three fits in succession. He had no
premonition of these attacks, or any subsequent ill feeling.
" Had been ploughing the day before he had the first attack ;
got better in a few days, and continued to work in various
places;" could not do much, changing often, "and always
finding something which did not suit him in every place he
tried." On the 18th of May, 1861, three days before his
death, he left Santa Clara and went home to his mother.
At 5 o'clock, A.M., on the 20th, he had a severe convulsion.
The family physician was called in, and bled him. The
convulsions were repeated frequently during the succeeding
day and night, and he expired at 10, P.M., May 21, 1861 —
twelve years, six months and eight days after the elate of his

342 RECOVERY AFTER

injury. These convulsions were unquestionably epileptic.
It is regretted that an autopsy could not have been had, so
that the precise condition of the encephalon at the time of
his death might have been known. In consideration of this
important omission, the mother and friends, waiving the
claims of personal and private affection, with a magnanimity
more than praiseworthy, at my request have cheerfully placed
this skull (which I now show you) in my hands, for the
benefit of science.*

I desire, here, to express gratefully my obligations, and
those of the Profession, to D. D. Shattuck, Esq., brother-in-
law of the deceased; to Dr. Coon, Mayor of San Francisco,
and to Dr. J. D. B. Stillman, for their kind cooperation in
executing my plans for obtaining the head and tamping iron,
and for their fidelity in personally superintending the open-
ing of the grave and forwarding what we so much desired
to see.

The missile entered, as previously stated, immediately an-
terior and external to the angle of the inferior maxillary
bone, proceeding obliquely upwards in the line of its axis,
passed under the junction of the superior maxillary and
malar bones, comminuting the posterior wall of the antrum,
entered the base of the skull at a point, the centre of which
is one and one-fourth inches to the left of the median line,
in the junction of the lesser wing of the sphenoid with the
orbitar process of the frontal bone — comminuting and re-
moving the entire lesser wing, with one-half of the greater
wing of the sphenoid bone — also fracturing and carrying
away a large portion of the orbitar process of the frontal
bone, leaving an opening in the base of the cranium, after
the natural efforts at repair by the deposit of new bone, of
one inch in its lateral, by two inches in its antero-posterior

* The skull and iron h ave been deposited, by the writer, in the Museum of
the Medical Department of Harvard University, in Boston.

SEVERE INJURY TO THE HEAD. 343

diameters, with a line of fracture or fissure leading anterior-
ly through the orbitar plate of the frontal bone, the anterior
fossa, and deflecting laterally, towards the median line,
divides the left frontal sinus, at the supra-orbitar notch, and
ascends the forehead along the left margin of the ridge, for
the attachment of the falx major. Inferiorly the line of
separation begins at the infra-orbitar foramen and the malar
process of the supra-maxillary from the body of the bone,
terminating at a point upon the superior maxillary opposite
the last molar tooth. — The bones implicated in its passage
were the superior maxillary, malar, sphenoid and frontal.
The iron, as you will perceive, entered the left cerebrum, at
the fissure of Sylvius, possibly puncturing the cornu of the
left lateral ventricle, and in its passage and exit must have
produced serious lesion of the brain substance — the anterior
and middle left lobes of the cerebrum-^disintegrating and
pulpifying it, drawing out a considerable quantity of it at
the opening in the top of the head, and lacerating unques-
tionably the upper aspect of the falx major and the superior
longitudinal sinus. As the iron emerged from the head, it
comminuted the central portion of the frontal bone, leaving
an irregular oblong opening in the bone of three and one-
half inches in its antero-posterior, by two inches in its lateral
diameter. Two of these fragments, as you will see from
the specimens before you, were re-united.*

* See plates at the end of this article, showing the direction of the passage of
the bar, lines of fracture in the skull, and the comparative size of the iron and
head.

344 RECOVERY AFTER

Remarks.

I. No attempt will be made by me to cite analogous
cases, as after ransacking the literature of surgery iu quest
of such, I learn that all, or nearly all soon came to a fatal
result. Hence I conclude to leave that task to those who
have more taste for it. This case is chiefly interesting to
me, as serving to show the wonderful resources of the sys-
tem in enduring the shock and in overcoming the effects of
so frightful a lesion, and as a beautiful display of the recupera-
tive powers of nature. It has been said, and perhaps justly,
that " the leading feature of this case is its improbability."
(Bigelow.) This may be so, but I trust, after what has
been shown you to-day, that the most skeptical among you
have been convinced of its actual occurrence — that it was
no " Yankee invention," as a distinguished Professor of Sur-
gery in a distant city was pleased to call it. Moreover, it
would seem, when we take into account all the favoring cir-
cumstances, that we may not only regard partial recovery as
possible, but exceedingly probable. These I will name
briefly.

1st. The subject was the man for the case. His physique,
will, and capacity of endurance, could scarcely be excelled.

2d. The shape of the missile — being pointed, round and
comparatively smooth, not leaving behind it prolonged con-
cussion or compression.

3d. The point of entrance outside of the superior maxil-
lary bone — the bolt did little injury until it reached the floor
of the cranium, when, at the same time that it did irrepara-
ble mischief, it opened up its way of escape, as without this
opening in the base of the skull, for drainage, recovery
would have been impossible.

4th. The portion of the brain traversed, was, for several
reasons, the best fitted of any part of the cerebral substance
to sustain the injury.

SEVERE INJURY TO THE HEAD. 345

II. This case has been cited as one of complete recovery,
it being ojften said that a very considerable portion of the
left cerebrum was lost, without any impairment to the intel-
lect. I think you have been shown that the subsequent his-
tory and progress of the case only warrant us in saying that,
physically, the recovery was quite complete during the four
years immediately succeeding the injury, but we learn from
the sequel that ultimately the patient probably succumbed
to progressive disease of the brain. Mentally the recovery
certainly was only partial, his intellectual faculties being
decidedly impaired, but not totally lost; nothing like de-
mentia, but they were enfeebled in their manifestations, his
mental operations being perfect in kind, but not in degree
or quantity. This may perhaps be satisfactorily accounted
for in the fact that while the anterior and a part of the mid-
dle lobes of the left cerebrum must have been destroyed as
to function, its functions suspended, its fellow was left intact
and conducted its operations singly and feebly.

III. Little has been said in the foregoing account as to
the treatment or conduct of this case, this being regarded as
quite unnecessary. The initiatory treatment, received from
the iron, though it might not be well received in this pre-
sence, you will permit me to say, was decidedly antiphlo-
gistic, a very large amount of blood having been lost. May
we not infer that this prepared the system for the trying
ordeal through which it was about to pass ? The recovery
is attributed chiefly to the vis vitce, vis conservatrix, or, if you
like it better, to the vis medicatrix naturce, of which this case
is a striking examplification.

I desire to call your attention, in passing, to two critical
periods in the progress of the case, when what was done
undoubtedly changed the tendency to a fatal result. The
first was on the fourteenth day, when the large abscess,
which probably communicated with the left lateral ventricle,

346 SEVERE INJURY TO THE HEAD.

was opened, followed by a marked improvement in all the
symptoms. The second was on the sixty-fourth day, at
which time he was bled sixteen ounces.

I indulge the hope, that surely but little if anything was
done to retard the progress of the case, or to interfere with
the natural recuperative powers. Nature is certainly greater
than art. Some one has wisely said, that vain is learning
without wit. So may we say, vain is art without nature.
For what surgeon, the most skilful, with all the blandish-
ments of his art, has the world ever known, who could pre-
sume to take one of his fellows who has had so formidable
a missile hurled through his brain, with a crash, and bring
him, without the aid of this vis conservatrix, so that, on the
fifty-sixth day thereafter, he would have been walking in the
streets again ? I can only say, in conclusion, with good old
Ambrose Pare, I dressed him, God healed him.

Fig. I.

Fig. 2.

Fig. 3.

View of the base of the skull from
within ; the orifice caused by the passage
of the iron having been partially closed
by the deposit of new bone.

View of the tamping iron,
and front view of the cranium,
showing their comparative size.

CASE OF EPILEPSY

PATHOLOGICAL INVESTIGATIONS.

By M. GONZALEZ ECHEVEERIA, M.D.,

SUPERINTENDENT OP THE MAHOPAC HOUSE FOB THE RELIEF AND CURE OF
EPILEPTICS AND PARALYTICS, LAKE MAHOPAC, N.T.

READ JUNE 3, 1868.

CASE OF EPILEPSY

There are phenomena connected with the history of
nervous diseases which, if studied and precisely defined,
may prove of great avail, not only in directing us towards
the means for the removal of their hurtful elements, but in
elucidating many other obscure questions regarding the
physiology and pathology of the nervous system. The
experimental researches undertaken to obtain the needful
information not unfrequently contradict each other, or disa-
gree with the results of pathological anatomy. Therefore,
comparative examination between the symptoms and the
structural changes should be instituted as the surest way of
getting a positive knowledge of the subject, and on this
account the following case is reported : —

Hattie K. W., aged twelve, born in Wopaca, Wisconsin,
entered the Mahopac Medical Institution, April 7th, 1868.
She was a slender, pale girl, not much developed for her
age. A brother of her maternal grandmother became
insane, upon injury to the head ( ? ), and her father died of
unknown disease causing extreme emaciation. She had the
first convulsions when six months old, while nursing and
teething ; the spasms were the sequelae of dysentery, which
attended with fever had previously affected the mother.
Convulsions were a symptom thereafter present each time
that the child was sick from any cause whatever, became
more and more frequent, and, three years ago, assumed an
epileptic character without any appreciable cause — unless it
46

352 CASE OF EPILEPSY.

be the change of climate from Wisconsin to Pennsylvania;
where her family resides. Has had measles and other
diseases of childhood, every one attended with paroxysms
of convulsions when they reached their height. When about
five years old she had scrofulous enlargement, without
suppuration, of the lymphatic glands of the neck. In the
beginning the attacks were limited to loss of consciousness,
occurring two or three times a day, then ceasing for several
weeks, and happening generally at night; latterly not as
much so as in the early part of the winter, during which
season she appears always worse. At first the convulsions
seized her suddenly, now she feels sick at their approach,
'•with something coming up her throat" — frequently asks,
"what shall I do ?" — and almost always screams after turning
very pale, and falls immediately backwards. The heart
beats also violently and the pupils are largely dilated before
the attack, during which she froths very little at the mouth,
bites the tongue and lips, and is a great deal convulsed. A
year ago urine was passed for a few times during the attacks ;
this does not now take place, nor does she wet her bed at
night. Occasionally she is irritable before the fits, and when
they repeat, she becomes very wild and bites and scratches
herself or the persons near her. She cannot stand or walk
after the attacks, and staggers on taking her first steps.
Between the fits she feels as though she were to be taken
sick, gets nervous, with palpitations of the heart, and sud-
denly runs away from the house without listening to any
calling. Once she went a mile before being caught, on
another occasion she escaped through the window of the room
where she was. Speech is thick after the fits ; there has never
been any dysphagia, nor impairment of sight or hearing,
nor unequal dilatation of the pupils ; when not drowsy she
talks wildly after the attacks, and sleeps seldom over half an
hour, but always does it between successive paroxysms.

CASE OF EPILEPSY. 353

In the intervening period between the fits she bites and
scratches herself, as already noticed, without consciousness
of what she is doing, but otherwise she is so sensitive, that
the least motion or touching of the limbs causes her great
pain. The temperature is lower in the right than in the left
side of the body ; she perspires freely, and chiefly on the right
side. Formerly she had a ravenous appetite after the
attacks, but now she goes without eating anything. The
breast has been enlarging for more than a year, and there
has been more or less pain in the loins and back. Her other
sisters menstruated at about twelve.

"When she arrived at the Institution she was in a very
excitable condition, having had eight attacks during the
journey to this place. She had a pale sickly color, her hands
exhibiting large eschars of injuries she had inflicted upon
herself during the fits. The temperature in the right limbs
and side of the face and neck was nearly one degree lower
than on the other side (82°). Hands and feet were cold
and purple. Pupils rather dilated, but of equal size. Tongue
coated at the centre ; breath with a strong, offensive odor.
She was very sensitive to touch j she could walk and run,
carrying herself with the trunk bent forward. Careful
inquiry made did not detect paralysis of any kind. The girl
was very talkative, prompt to reply, and her mother, who
gave the above information, stated that her memory was very
good, although in other respects the mind was decidedly
impaired and her temper soured. The urine of the night
examined the next day after she arrived, was acid, of light
color, density 1021, without albumen or sugar, and loaded
with triple phosphates. Pulse irregular, very weak, and
ranging from 90 to 96. She was free from headache, and
her bowels had not acted in some days.

Exclusive of some homoeopathic treatment, the girl had
never had anything done to her, and for three years past had

354 CASE OF EPILEPSY.

manifested no change excepting in the summer of 1866, when
she was for seven months free from paroxysms.

She was ordered: Potass, bromidi, gr. xxx. ; ammon.
bromidi, gr. x. ; decoct, calumbae, f. § ss. ; misce ; to be taken
three times daily. In addition : Ext. bellad. gr. -J ; ergotine,
gr. ij. ; misce ; ft. pill, to be used night and morning. She was
to be packed eyery morning in the wet sheet, to have a very
short shower bath towards evening, to exercise in light
gymnastics, and to be put under a nutritious diet with beef,
cream, claret, coffee/ &c. She was also kneaded and rubbed
every night and morning.

The first night she had several fits, and another paroxysm
the next morning after breakfast ; she became irritable, and
evading the vigilance of the nurse run away from the room
where she was ; the attacks repeated themselves through the
night, and eight times again the following night. The dose
of bromide of potassium was then carried up to forty grains
every four hours. The convulsions ceased entirely from
that time, but she continued complaining and crying whenever
she was touched. The appetite failed more and more, until
she would not eat anything ; the breath turned excessively
offensive, and a thick, white discharge ran from the mouth ;
this discharge existed before the bromide was used, though
not so profusely, and diminished very much with a solution
of permanganate of potash used as a wash. The appetite?
however, did not improve ; she would not swallow any solid
food, and on one occasion the small parcels of beef, given to
her the day before, came away the next morning upon wash-
ing out the mouth. She could not walk without staggering,
or losing the equilibrium, and would scream if she were
touched on any part of the body. If left alone she would
bend down, to lie upon the floor. The mind, notwith-
standing, continued unimpaired. Stimulants and nourish-
ment bv the mouth and rectum failing to invigorate her. or

CASE OF EPILEPSY. 355

to remove this condition, she died May 10th. The bromide
was discontinued three weeks before her death; the girl
became comatose about twenty hours before expiring, and
even until the beginning of this stage she would utter a cry
as soon as touched in any part of the body. The pupils,
naturally dilated, remained to the last responsive to light.
The extremities were very cold, and livid, upon the feet the
epidermis was in some places raised by limpid serosity, form-
ing large phly ctama. The bowels did not act without injections ;
but there was no retention of urine. Finally, I may state
that the case was diagnosticated as one of epilepsy connected
with lesion of the cerebellum — probably a tumor.

I obtained permission to examine the brain, and aided by
Dr. "W. Royster, Assistant Physician to the Institution, the
skull was opened fifty hours after death, the body having
been kept in ice. The calvaria was so thin that in the
upper part the diploe had entirely disappeared, making the
bone quite transparent * the inner table easily separated from
the dura mater, which was very congested. No adhesions
between the membranes and the brain,* the former gorged
with dark blood, and distended by a limpid serosity filling
the sulci between the convolutions. Brain tissue very moist,
firm and highly congested, its cut-surface exhibiting throughout
a sandy appearance. The same congestion was found in the
cerebellum, but the left hemisphere had undergone a degen-
eration involving the corpus dentatum, and giving to the
tissue a lardaceous resistance when cut through. The degen-
eration was in the main bloodless, irregular in outline, of a
yellow-whitish tint, and limited to the cerebellum without
extending into the neighboring regions.

The oblong medulla with portion of the spinal cord to the
level of the second cervical nerves, and also a small frag-
ment of the cerebellum, were saved for further micro-
scopical examination. I did not detect any membrane en-

356 CASE OF EPILEPSY.

cysting the lesion in the cerebellum, which had the mi-
croscopical characteristics of the cholesteatoma. It was
composed of oval scales and rectangular tables of choles-
terin, mixed with granular amorphous matter, interwoven
with fibriles and nuclei of connective tissue. The capillaries
around this texture were varicose and finely granular
throughout. I did not discover any granular corpuscles in
this part, but fatty globules and molecules were interspersed
throughout the connective tissue. There was no such degen-
eration in the pons varolii ; here, however, was observed the
condition already noticed with the capillaries of the cerebel-
lum, an increased amount of amorphous matter mixed with
fatty granules, and some amyloid corpuscles. The most
remarkable change existed in the spinal cord. This was
hardened in alcohol, and different thin sections made, which
were put up in glycerine for minute microscopical examination.
The cord when fresh exhibited a softened condition of its
grey substance. Under the microscope the left anterior and
posterior cornua, as well as the parts around the central
canal, were considerably destroyed. The structure had here
a gelatinous appearance, stretched across by very fine and
brilliant fibres of neuroglia mixed with granular amorphous
matter, and portions of capillary vessels irregularly distended,
and having undergone the granular condition peculiar to
epilepsy. Only part of the caput of the posterior cornu had
escaped destruction, and as to the anterior cornu it had
nearly disappeared. It would have been interesting to
ascertain the extent of this degeneration throughout the
cord. The grey substance was equally but irregularly
involved in the medulla oblongata, and much changed in its
structure, particularly at the origin of the hypoglossus.

The main features of the case here described and so
rapidly brought to a close, suggest interesting comments.

CASE OF EPILEPSY. 35

The complete arrest of the spasms upon the exhibition of
large doses of bromide of potassium, and the complete
inability of the patient to recover, seem to be not casual
coincidences, but facts connected with each other. It was
evident, when the girl entered the Institution, that the disease
was in active untoward march, the spasms were more frequent,
attended with marked impairment in the mental condition of
the child and emaciation. No treatment had been opposed
to all this mischief, and it would seem as if the bromide of
potassium, after controlling the disturbance in the cerebral
circulation, arrested the chief source of convulsions, without,
however, having an influence over the alterations of the
nervous system, already too far advanced to permit a renewal
of their exhausted activity. However this may be, the
phenomenon is interesting. The most striking point in
reference to the case is that of the state of the spinal cord,
which brings further evidence against the theory regarding
the transmission of sensitive impressions put forward by
Brown-Sequard. In this instance the central grey matter,
the cornua, and the very extremities of the posterior cornu,
were deeply altered, and yet sensibility was increased
instead of lost, notwithstanding such an extensive damage to
the channel through which it is supposed to be transmitted.
In the British and Foreign Medico- C Mr urgical Review for
April, 1864, there is the report of a case of paralysis by I.
Russcl Reynolds, with pathological investigations by Lock-
hart Clark. This distinguished anatomist found that the
central grey substance of the cord was destroyed on both
sides, with painful hyperesthesia of the left arm, and not the
slightest impairment of sensibility of the trunk and lower
extremities. From this and other similar cases falling under
his observation, Clark has been led to reject the above
theory : he does not believe that sensitive impressions are
conveyed from the anterior or posterior extremities to the

358 CASE OF EPILEPSY.

brain, and that voluntary impulses are transmitted in an
opposite direction to the same parts, exclusively and uninter-
ruptedly by the grey substance ; but that this substance is the
conductor of any given impression only for a certain but
variable distance. My own investigations agree in results
with those of Lockhart Clark. I have reported, in the New
York Medical Journal for April, 1865, a case of apoplexy of
the spinal cord, in which the grey substance had in many
places been injured in its whole width without causing
anaesthesia. Since that time I have also met with a very
remarkable instance, in which the grey substance of the cord
had in many places undergone an extensive fatty degenera-
tion and sclerosis, also involving the white substance, and
yet the patient never complained of any loss or other impair-
ment of sensibility. The patient died suddenly whilst
straining to relieve his bowels. On post-mortem examina-
tion, evidences of cerebral softening, with atheromatous
degenerations of the cerebral blood-vessels, were apparent
to the naked eye. There was also an aneurismal enlarge-
ment of the vertebral arteries, and the dilatation of the right
side burst during the effort, producing hsematorrhachis and
instantaneous death. I preserve a photographic copy of
this interesting specimen, showing a clot plugging the vessel
and determining its distention — a not unfrequent source of
aneurism, first pointed out by Dr. John W. Ogle, and which
I have repeatedly found to be the cause of the dilatation of
the cerebral and spinal arteries, observed in delirium tremens,
softening of the brain and epilepsy.

Lake Mahopac, N. Y.; June 1,. 1868.

CASES IN ORTHOPEDIC SURGERY.

(With Photographs.)

By BUCKMINSTER BROWN, M

READ JUNE 3,, 1868,

ORTHOPEDIC SURGERY.

Members of the Profession, both those residing in the
city and those coming from a distance, are frequently re-
minding me that cases showing the results which can now
be attained by combined operative and mechanical surgery,
in the treatment of deformities, possess a great interest for
the general practitioner. Acting upon these suggestions, it
is proposed at this time to state, in few words, the history
of several cases, most of which have recently come under
my observation, and are brought forward as examples of
some of the various classes into which this branch of sur-
gery is divided. The better to elucidate the subject, casts
or photographs will be shown, before and after treatment;
and, in two or three instances, I am enabled to present the
patient to the Society for examination.

Case I. Casts Nos. 1 and 2. Photographs 1 and 2.

Talipes. — The first case to which I will draw attention is
the one from which this cast and this photograph were taken.
(See Case L, Plate L, figure 1.) A boy born with such a
distortion of the leg and foot that the great toe was turned up
against the side of the knee, and, when the child was awake,
was in close contact with the internal condyle of the femur.
The tibialis anticus and posticus muscles were strongly con-
tracted— structurally shortened. The treatment consisted in
the division of the tendons of these muscles, and in the use
of a variety of apparatus, employing sometimes the spring

362 CASES IN ORTHOPEDIC SURGERY.

and sometimes the screw power. By these means the leg
and foot were gradually brought into a normal position.
By the time, however, this result was somewhat more than
half accomplished, the tendons, growing more rapidly than
the bones, had united, and again presented an obstacle to
further improvement. These were re-divided, and, in about
six months, the result was as shown in the second cast. (See
Case I., Plate L, figure 2.) The second photograph gives
a correct idea of the foot when it was nearly straight.
When I last saw the child, he walked on the sole of his foot.

Case II. Casts Nos. 1, 2, 3, 4.

This is a case of paralytic calcaneo-valgus, the result of
spiua bifida. (See Case IL, Plate I., figures 3 and 5.) The
patient is a girl eleven years old. It is evident that in the
left foot the articular facet of the astragalus, instead of
being applied against the internal malleolus, does not enter
into the composition of the ankle-joint, but, with its rounded
internal face, and with the scaphoid, forms the projection on
the inside of the foot. It will be seen that the front part
of the foot is higher than the heel, therefore it is calcaneo-
valgus; yet, in reality, from the displacement of the cal-
caneus, the origin and insertion of the gastrocnemius are
approximated. Thus is presented the somewhat anomalous
state of the parts in which, although treating a case of cal-
caneus, instead of desiring to shorten the tendo-Achillis, we
are obliged to increase its length before the foot can be re-
placed. The tendons divided in the left foot were the three
peronei, the extensor longus-communis, extensor pollicis-
pedis, the tibialis anticus and the tenclo-Achillis. The same
tendons were divided in the right foot, with the exception of
the tibialis anticus and the tendo-Achillis. I here present
the models of the feet, as they were before treatment, and

CASES IN ORTHOPEDIC SURGERY. 363

four months after the commencement of treatment. (See
Case II., Plate I, figures 3, 4, 5, 6.) The child is able to
walk on the soles of the feet.

Case III. Casts 1 and 2. (Patient present.)

There are but few cases in which the patients are so situated
as to appear on such an occasion as this. Either they live at
too great a distance, or they dislike to be presented. This
boy, however, willingly comes forward. He well illustrates
the legitimate results of the combination of operative and me-
chanical surgery. He is nine years of age. He had con-
genital varus of the right foot. Continued use of the foot
had converted it into what has been termed varo-dorsalis.
The foot had been operated upon some years previous to
coming under my care. I divided the tibialis anticus, plantar
fascia and tendo-Achillis. (See Case III., Plate II., figures
1 and 2.)

Case IV. Cast No. 1, and Patient.

I have here a cast of one foot from a case of double tali-
pes varus. The feet were alike. (The patient will stand
upon the table, or walk around, that gentlemen who wish
may examine her feet.) (See Case TV., Plate IL, figures 3
and 4.)

Case V. Casts Nos. 1 and 2, and Patient.

This cast (see Case V., Plate IL, figure 5) speaks for
itself. The child is three and a half years old. She had
paralytic varus. The tendo-Achillis, tibialis anticus and
posticus, and extensor longus pollicis pedis were rigidly con-
tracted. These tendons were divided in February, 1868.
In twenty days after the operation, the paralyzed muscles,

364 cases m orthopedic surgery.

no longer kept fully extended by their contracted antagonists,
completely recovered their power, and the child was able to
flex and abduct the foot. A cure was effected in two months.
(See Case Y., Plate II., figure 6.) The child is now under
treatment for contracted knee, arising from the same cause.
The biceps flexor cruris has been recently divided.

Paralysis is rarely the cause of congenital varus. Non-con-
genital varus, however, frequently arises from paralysis of a
single muscle or of a set of muscles. On the other hand, the
etiology of both congenital and non-congenital valgus may so
constantly be traced to debility of muscles and ligaments —
amounting, in the majority of cases, to complete paralysis —
as almost to form the rule in this class of cases. The return
of power to the paralyzed muscles I have frequently observed
after division of the healthy muscles, which are structurally
shortened in consequence of the normal balance of power
having been destroyed.

Case YI. Casts Nos. 1 and 2.

Within a year or two, much lias been said and written in
regard to the cure of talipes without tenotomy. This case
may be cited (one among several that could be referred to)
as a fair instance of the result of such attempts. (See Case
YL, Plate III., figure 1.) The child from whom the cast
was taken was born with double talipes varus. A few days
after birth the treatment by apparatus was commenced, and
was continued two years. For three months the patient
was visited daily by the attending surgeon. The result
after two years, was a failure, as is shown in the first cast,
taken when he came under my treatment. The second cast
was taken three months afterwards. (See Case YI., Plate
III., figure 2.)

CASES IN ORTHOPEDIC SURGERY. 365

Case VII. Casts Nos. 1 and 2.

The cast I have in my hand (see Case VII., Plate III., fig-
ure 3), represents a case of varus, interesting from the fact
that a somewhat similar attempt to the preceding had been
made to cure the foot. It has been said the hand of the
mother or nurse is in truth the best apparatus. In this case
the mother, instructed by her physician, had devoted herself
to the task. She had held the foot in her hands, on the
stretch towards a straight line, four hours a day for three
months. Flexion was impossible from any force that could
be applied to it. That her labor was thrown away is shown
in this first cast taken when the patient was brought to
Boston. This second cast shows the foot after tenotomy
and subsequent treatment. (See Case VII., Plate III., fig. 4.)

Case VIII. Casts Nos. 1 and 2.

I have cited cases showing the nugatory effects of pro-
tracted mechanical treatment without operation. Here are
a couple of casts, not remarkable in themselves, but in-
teresting as examples of numerous cases exhibiting the
same or worse results from the opposite mode of treatment,
viz. : — too much surgery without appropriate after-treatment.
The lad, from whom this model was taken, had been operated
upon six times by a distinguished New York surgeon. The
tendo-Achillis was divided three times. After five years
treatment the foot was as malformed as at first. (See Case
VIII., Plate III., figure 5.) The second model was taken
after the boy had been in Boston three months. (See Case
VIII., Plate III, figure 6.)

Case IX. Casts Nos. 1 and 2.

These casts furnish another instance of the fact just al-
luded to. The boy had double varus, third degree. He

366 CASES IN ORTHOPEDIC SURGERY.

had been operated upon ten or twelve times ; and had like-
wise been under treatment five years by surgeons in New
York and at the West, with the disastrous result seen in the
first cast. (See Case IX., Plate IV., figure 1.) The second
cast shows the feet (they were alike) when he left Boston.
(See Case IX., Plate IV., figure 2.) .

Cases X. and XL Casts.

In order to make the series more complete, there are on
the table, one sample of talipes equinus before and after
treatment (See Case X., Plate IV., figures 3 and 4) ; also
casts of a case of varus, treated several years since, intro-
duced simply to show that the growth and strength of the
limbs are not diminished by somewhat extensive tenotomy.
The case was one of extreme double varus. The tendo-Achil-
lis in each foot was twice divided, also the tibialis posticus
and flexor longus pollicis pedis. The boy was treated and
cured, when eight years of age. The second cast was taken
twelve years afterwards. (See Case IL, Plate V., figures
1 and 2.) These years the lad had passed chiefly at sea,
doing duty as a sailor. He has since become master of a
vessel, and states that he has never experienced the slightest
inconvenience from his feet.

Case XII. Casts Nos. 1 and 2.

This is an example of a case of genu varum or bow-legs.
Both legs were similarly affected. It is curious to notice,
that, although the legs were tightly strapped on the convex
side for months, yet the healthy growth and development
were not impeded, as is well shown in the second cast.
(See Case XII., Plate V., figures 3 and 4.)

CAgES IN ORTHOPEDIC SURGERY. 367

Case XIII. Photographs Nos. 1 and 2.

This photograph (see Case XIII., Plate VI., figure 1) re-
presents the legs of a little girl as they were when she came
under treatment. It was a bad case of genu-valgum of the
right leg, and genu-varum of the left. The result, as shown
in the accompanying photograph, was attained by apparatus
without tenotomy. (See Case .XIII., Plate VI., figure 2.)

Case XIV. Photographs Nos. 1 and 2.

These photographs were taken from another case, of a
similar nature to the preceding, before and after treatment.
In this case, also, no operation was required. The distor-
tion, in both instances, was caused by malformation of the
joints, uncomplicated by muscular contraction.*

Lateral Curvature of the Spine, or, according to the
latest and best authority,? " Potato-Lateral Curvature," in
its advanced stages, is one of the most discouraging affec-
tions with which we have to deal. Much, however, can be
accomplished by patience and perseverance. In spinal cur-
vature, as in most other cases pertaining to this branch of
surgery, frequent variation of the treatment, and, where ap-
paratus is employed, a frequent change in the appliances, is
required. { They should be modified according to the exi-
gencies of the case, adapting the means employed to the

* The photographs of Case XIV. are not copied for publication, as the case re-
sembles that represented on Plate VI.

f On Spinal Weakness and Spinal Curvature ; its early Recognition and Treat-
ment. By W. J. Little, M.D. London, 1868.

+ This rule applies, with especial force, to talipes. In every species of club-
foot, excepting where the twist is very slight, from two to six, or even more
varieties of apparatus are often required to make a perfect foot.
48

368 CASES IN OETHOPEDIC SURGERY.

changes in the form as the cure proceeds. It may be interest-
ing to mention an extreme case of this complaint which has
recently come under my observation.

Case XV.

Miss , aged 31. Has had curvature of the spine from

childhood. Her body, from neck to hips, has gradually
shortened. For this there is a partial compensation in the
greatly increased antero-posterior diameter of the chest.
On examination, I found the crest of the ilium, on the left
side, to be two inches fromt he axilla. On the right, the dis-
tance is two and three-fourths inches. In fact these bones
are lodged directly beneath the shoulders. The os pubis is
three and one-half inches from the sternum. Relief, by an
accurately adjusted support, was the only treatment admissi-
ble. Such extraordinary cases are rarely met with.

Case XYI. Photographs 1 and 2.

Here is a photograph of the back of a boy from Law-
rence, Kanzas. (See Case XVL, Plate VIL, figure 1.) He
had severe lateral curvature. The left hip was very promi-
nent. The trunk, above the hips, was thrown so far to the
right, that the centre of the occiput was on a line with the
right leg ; consequently, in standing, the weight of the
body was sustained by this leg. The right scapula and ribs
projected,, and the left scapula sank into the hollow formed
by the curve. This unequal distribution of the weight of
the body had produced an inward inclination of the left
knee. The second photograph (See Case XYI., Plate VIL,
figure 2) shows the state of the spine some months since.
It is now still further improved. The left shoulder, formerly
much below the level of the right, is now the higher. This
will rectify itself. The knee was cured by proper apparatus.

CASES IN ORTHOPEDIC SURGERY. 369

Caries op the Cervical Vertebra, compared with the
same affection as it attacks other regions of the spinal col-
umn, is a rare disease. Some years since I published an
account of a case of caries of the upper bones of the neck,
remarkable in many points of view, which terminated fatal-
ly. The atlas, axis and base of the cranium were eroded,
and death was caused by fracture of the odontoid process.
The pathological appearances were minutely described.
About the same time two or three similar instances presented
themselves, which were also fatal. Since then I have treated
other cases of cervical caries which have had a more favor-
able termination. There are present, to-day, two children
who have been sufferers from this disease.

Case XVII. (Patient.)

This little girl, when I first saw her, eleven months since,
had lost all voluntary power below her neck. She could
speak in a whisper. The only muscles not paralyzed were
those connected with the eyes and mouth. She had been in
this state some months. There was swelling and prominence
of the lower cervical vertebrae. In February, 1866, an ab-
scess formed in the neck, which continued discharging, at in-
tervals, for twelve months. She then began to lose the use
of her right arm and leg. The paralysis extended, involv-
ing both arms and legs, with inability to move the head.
For a time the bladder was implicated, and the use of a
catheter was required. She had paroxysms of severe pain
in the lower cervical vertebras. The child, as you see, is
now well and without deformity. There is scarcely a trace
of the disease remaining.

I have recently been informed that the elder sister of this
patient died of caries of the dorsal vertebrae, after having
been paralyzed three years.

370 CASES IN ORTHOPEDIC SURGERY.

Case XYIII. (Patient.)

This boy had the same disease in about the same situation.
The symptoms, also, were very nearly similar, but had been
of longer duration when he came under my observation.
There was complete paralysis of all the voluntary muscles
below the mouth. He had been unable, for months, to move
his head, or to bend a finger or a toe, or to speak above a
whisper. Severe pain was produced if any attempt was
made to bend his fingers, wrists, knees or ankles. The
joints were stiff. He had incontinence of urine. The res-
piratory muscles acted imperfectly, and his breathing was
labored. His countenance expressed suffering, and his man-
ner of rolling his eyes, to compensate for inability to move
his head, gave him a very singular appearance. The paraly-
sis commenced about ten months previous to his being placed
under my care. Power of motion returned first to his fingers,
and gradually extended, and in three months he began to walk.
The treatment consisted, iu the first place, of mechanical sup-
port to retain the head in one position. The apparatus was
a spring collar, resting on the clavicles and shoulders,
with branches running down the back, and secured by a
belt. Passive exercise of all the joints was perseveringly
employed. Friction, electro-magnetism, the pyro-phosphate
of iron, and cod liver oil were important adjuncts. Chloro-
form was given internally, to relieve pain. In this case it is
interesting to notice that the efforts of nature to cure the
disease have exceeded the necessity ; and there has been a
great amount of ossific matter thrown out around the bones,
producing considerable deformity of the neck. An abscess
formed and opened spontaneously. The boy is now able to
walk long distances, carrying bundles and going on errands.

CASES IN ORTHOPEDIC SURGERY. 371

Case XIX. (Patient.)

Hip Disease. — It is impossible, in the brief time to which
these papers are necessarily limited, to give more than a very
imperfect sketch of the various diseases, and their effects in
deranging and distorting the human frame, "which receive their
proper classification in the branch of surgery we are now
considering. The cases already brought forward are of prac-
tical importance. Those last introduced, all will acknow-
ledge, are eminently so. They are instructive instances of
the recuperative powers of nature, aided and guided by art j
and teach us how much these may be relied upon even in
cases which appear utterly hopeless. I should be glad, if
time permitted, to draw your attention to the several varie-
ties of hip disease, referring to the diverse, and sometimes
almost opposite modes of treatment appropriate to the dif-
ferent cases and to the different stages of the same case.
The interest attached to these would be increased if the pa-
tients, showing in their persons the results, could be pre-
sented to you as in some of the preceding cases. My limits
permit me, at this time, to bring forward one patient only.
He suffered from morbus coxarius from August, 1866, to
March, 1867. When first seen by me, in October, 1866, he
could not bear the slightest touch in the neighborhood of the
left hip, and had severe pain in this joint and in the knee.
He had frequent startings in the night, waking and scream-
ing with pain. The patient was seen by Dr. J. Mason War-
ren, and other surgeons, during the early months of the
disease. The treatment was directed, in the first place, to
relieving the symptoms of acute action within the joint. It
has been much the fashion of late, for surgeons treating hip
diseases, and those analogous, of the spine, to discard, as old
fashioned, all counter-irritants and antiphlogistic remedies.
Let me urge them not to do this in every case. There are
certain varieties and phases of these diseases in which there

372 CASES IN ORTHOPEDIC SURGERY.

are no other means of relief possible. Mr. Pott was not so
utterly mistaken as many in these days would have us be-
lieve. There are cases of disease of the hip or spine
in which a modification of his treatment is of incalculable
benefit, and it is only on account of its indiscriminate em-
ployment in all varieties of these complaints, in many of
which disappointment has attended its application, that it
has fallen into discredit.

In the earlier stages of some species of hip disease, for
example, we have too frequently seen the severe pain, the
extreme tenderness of the joint, where the slightest jar is
agony, the nocturnal startings and spasms, and the pain in
the knee removed, after having existed for months, by flying
blisters, or by an issue, preceded, if the state and history
of the patient render it advisable, by slight local blood-let-
ting, to have a doubt left in our minds in regard to the im-
portance of these remedies. The relief is often immediate ;
neither extension, nor rest, nor internal remedies will have
the slightest effect in such cases, without the aid of local
applications in some one or more of the forms which experi-
ence has taught us are most beneficial. Quiet nights and
comfortable days were the immediate results of this course
in the case now under consideration. A hip-splint was ap-
plied, complete rest enjoined, and slight extension was used.
The apparatus employed had especial reference to the pre-
vention of contraction or permanent displacement at the
joint, one of the most frequent and unfortunate sequelae of
this disease, to obviate which requires the exercise of the
utmost caution. The boy has been, for more than a year, in
as perfect health as you now see him. There is not the
slightest limp. That the hips are alike in appearance and
perfectly normal in action, will be acknowledged by those
who will examine the patient.

The importance of attention to position in hip complaint

CASES IN ORTHOPEDIC SUKGERY. 373

cannot be too strongly insisted upon. It may be useful, in
this connection, to refer to a case which, probably, has not
its counterpart upon record. It was that of a young girl,
who was brought to me from a distance, a few years since.
She was thirteen years of age, and had suffered, for many
months, from double .hip disease. She had gone through
the several stages of the complaint, and it had terminated
in anchylosis. From malposition, during the acute periods,
both thighs had become permanently fixed at right angles
with the sides of the body, on a line with the axillae, and
parallel with the arms when stretched in such a manner as
to afford the fullest expansion to the chest. In sitting, the
lower limbs projected over the sides of the chair. The head
of each femur was joined to the acetabulum by a solid, bony
union. The case was irremediable. A greater misfortune
can scarcely be imagined. Double excision at the hip joint
was a procedure maturely considered, but decided not to
be advisable under the circumstances.

Torticollis, a less common complaint than any of the
preceding, has some curious features which are worthy of
notice. Its causes are various. Frequently it arises from
contraction, congenital or non-congenital, of one or both
branches of the sterno-cleido-mastoideus muscle, sometimes
combined with a similar affection of the trapezius or scaleni.
Spasm, permanent or intermittent, the cicatrices of burns,
and paralysis, may give rise to this affection. Other in-
stances of wry neck originate in rheumatic inflammation of
one or all of the muscles just named. I have found the
trapezius condensed into a firm, indurated tissue, apparent-
ly as unyielding as ligament. I have also seen very serious
distortion arise from rheumatism attacking the inter-verte-
bral substance between two or more of the cervical vertebras.

374 CASES IN ORTHOPEDIC SURGERY.

This disease will produce swelling and permanent thicken-
ing of the ligamentous tissue on one side, the bone, perhaps,
being implicated, while the muscles are not at all, or but
slightly involved. The peculiar, characteristic, rotatory
twist, in these instances, is less observable than in other va-
rieties of torticollis. Those cases originating in the causes
first mentioned are generally incurable without division of the
offending muscles. The last named may, often, be completely
relieved by apparatus and appropriate remedies. An ap-
pliance which shall fix the head, and enable us to act upon
it steadily and firmly, has been a desideratum in surgery,
not only for the treatment of the complaint we are now con-
sidering, but, also, when dealing with the deformities arising
as a sequence of burns and from other causes. I have
seen but one apparatus that does this effectually. It was
invented by Dr. John B. Brown, some years since. This
instrument answers every indication in torticollis, and, for
accomplishing the object desired, is nearly perfect. We have,
in this affection, to contend, first, with the sideward inclina-
tion of the head, which sometimes almost touches the
shoulder ; secondly, with the rotation, by which the face is
turned towards the opposite shoulder; thirdly, with the
tendency to stoop, or posterior curvature of the dorsal
vertebrae ; and, fourthly, with the lateral curvature, which
is the inevitable result of the disturbance of the equi-
librium above. The apparatus referred to, consists of
a padded steel belt, which firmly grasps the pelvis. From
the centre, opposite the sacrum, arises a strong steel
upright, terminating in a steel skull-cap, which encircles
the head, with a tongue, projecting obliquely downwards
and forwards, to press upon the superior and inferior
maxillary bones. There is a crutch, on one side, to
balance the instrument and to support the depressed
shoulder. A broad belt, also of steel, attached to the back

CASES IN ORTHOPEDIC SURGERY. 375

upright, embraces the body below the axillae, and buckles in
front. About two inches below the cap, upon the posterior
standard and opposite the cervical vertebrae, is a circular
ratchet-wheel which acts in such a way as to rotate the head ;
below this, another, working in a different direction, tilts the*
head towards either shoulder. A third ratchet-wheel, oppo-
site the middle dorsal vertebrae, acts antero-posteriorly, and
corrects the stoop which is a frequent accompaniment of
torticollis. A fourth is placed near the insertion of the
standard to the pelvic belt. This turns from side to side,
and, by means of the upper belt, below the shoulders, un-
bends the lateral curve of the spine, which, as has been
stated above, is always present in a confirmed case of wry
neck.

For the milder varieties of this affection, where less power
is required, I have contrived a less complicated but very
efficient instrument. This is a double spring stock to sustain
the head, from which two pieces of steel, about a foot long
and half an inch wide, extend down each side of the spine
and are secured to the waist by a leather belt. There is a
check for the chin, and a spring against the occiput, by which
the head is turned and retained in a position the reverse of
that towards which it is abnormally inclined.

Another of the sequelae of torticollis is the series of re-
markable twists which gradually occur in the facial linea-
ments. The physiognomy becomes characteristic. The
eyes, nose, mouth, and even the eye-brows, endeavor to adapt
themselves to the one-sided position of the head. There is
a persistent, involuntary effort made, by the muscles, to com-
pensate for this obliquity and to restore the normal, relative
position of the features. This, in time, produces a very
peculiar appearance of the countenance, which is pathogno-
monic of the complaint.
49

376 CASES IN ORTHOPEDIC SURGERY.

Case XX. Photographs Nos. 1 and 2.

The last case, of which I have to speak this morning, is
that of a girl twenty years of age, whose situation before
treatment is shown in this photograph. (See Case XX.;
Plate VIII., figure 1.) When eleven years old, while at
play, she was thrown from a height of sixteen feet, by the
caving in of an embankment, the lumbar and sacral spine
striking upon a large stone. The fall produced insensi-
bility for a few moments. She then recovered and went to
school. She continued her usual avocations for five or six
weeks, growing, daily, more and more feeble. She was then
attacked with agonizing pain in the lumbar region, followed
by complete loss of sensation and motion below the hips.
The thighs and legs gradually contracted, until the left knee
was forced against, and under, the right thigh, and the thigh
was drawn up to an acute angle with the body, and twisted to
the right. These parts were in such close contact that
it was with difficulty I forced the knee from under the thigh
where it had lain for years. The patient had extreme
lateral curvature, with excessive incurvation of the lumbar
vertebrae. She had been in this situation nine years. By
means of subcutaneous division of tendons in the groins,
popliteal regions and in the feet, followed by mechanical
appliances, together with a carefully adjusted spinal support,
the girl was in three months straightened out as seen in the
second photograph. (See Case XX., Plate VIII., figure 2.)

There are other photographs and models upon the table,
for examination, by any gentlemen who may feel interested.

PLATES.

The figures in the accompanying Plates are photo-
graphic representations of most of the cases de-
scribed in the preceding paper. They are copied
with an accuracy only attainable by that wonderful
art which permits the subject to stamp its own
image.

Each one is the type of a class, or is illustrative
of practical facts referred to in the text, and is in-
dicated by numerals under the appropriate heads,

PLATE I.

J.' J. HAWES,

CASE I.

Fig. 1. Before treatment. Fig. 2. After treatment.

CASE II.

Fig. 3. Left foot before treatment. Fig. 5. Right foot before treatment.
Jug. 4. Left foot after treatment. Fig. 6. Right foot after treatment.

PLATE II.

i. I. -i'-viS,

CASE III.

Fig. 1. Before treatment. Eig- 2- After treatment.

CASE IV.
Fig. 3. Before treatment. Fig. 4. After treatment.

CASE V.
Fig. 5. Before treatment. Eig. 6. After treatment.

PLATE III

case vr.

Fig. 1. Before treatment.

CASE VII,
Fig. 3. Bafore treatment. Fig. 4

Fig- 2. After treatment.
g- 4. After treatment.

CASE VIII.
Fig. 5. Before treatment. Fig. 6. After tr

eatment.

J. J. HAWES,

PLATE IV

CASE IX.
Fig. 1. Before treatment. Fig. 2. After treatment.

CASE X.

Fig. 3. Before treatment. Fig. 4. After treatment.

J. J. HAWES,

PLATE V .

CASE XI.
Fig. 1. Before treatment. Fig. 2. Twelve years after treatment.

CASE XXI.
Fig. 3. Before treatment. Fig. 4. After treatment.

*. J. HAWES,

PLATE VI

CASE XIII.

Fig. 1. Genu-valgum of right leg, before treatment.
Grenu-varum of left le°- " »

Fig. 2. After treatment

J. i. HAWES,

PLATE VII

CASE XVI.
Lateral Curvature. Pig 1. Before treatment. Fig. 2. After treatment.

PLATE VIII-

CASE XX4

DXSTOBTIO* OK THE SPI-« AND LlMBS-

Fi"- 1. Before treatment.

Fig. 2. After treatment.

,. KAWES,

(Mar,, 1887, 20,000)

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